Ablation booked at Bordeaux - I just need someone to talk me into going through with it!

Hey everyone,

I've been following this board since my atrial fibrillation started in August 2009. Since that time I've went from 1 to 2 attacks a year to monthly attacks to short attacks almost daily. At that point, around 14 months ago, I started taking daily Propafenone. I stopped taking that about two weeks ago because it appears to be causing peripheral neuropathy in my feet. I decided I'm not going to flecanide and it was time to pull the plug and get an ablation.

My doctor here is willing to do it and he's a super nice guy. Speaking to his nursing staff he does one procedure a week so probably 40+ per year. I have always told myself if I was going to do this I wanted to get the best chance of a one and done. Going to Natale is prohibitively expensive for me as a Canadian so I chose Bordeaux.

My electrophysiologist, while not disapproving per se, will not help to facilitate me getting a transesophageal echo cardiogram or anything else and states that he will continue to accept me as a patient but will not do a Second procedure if the first one is not successful.

I'm starting to wonder if I'm making a $25,000 mistake and should perhaps get my local doctor to give it a shot for free. I had not spoken to my local doctor about his success rates but I think it was around 60 some percent two years ago for a first procedure.

I know Adrian had a procedure done by this doctor and we spoke about this a couple of years ago. As well RonB went from Alberta to Bordeaux and had a positive experience. Are there any other Canadians here who made that leap?

Obviously this is a personal choice but I would really be interested in hearing peoples opinions on this.
On a related note, for those that have gone abroad for such procedures, have you taken out "complication insurance"?

Best regards,
Monty

Monty,

I can only suggest what Shannon always says----the heart is a very delicate organ. Try to find the best ablationist you can.

I went to Natale for a 1/27/15 ablation. My afib was diagnosed on 1/14/14 and continued to progress, much like you described, but at a quicker pace. I tried Flecainide at varying doses but none of them worked well. Prior to the ablation, I was almost always in afib.

The ablation from 1/27/15 has given me a second chance.

I would encourage you to find the best ablationist in your area, if you are unable to travel to Natale or other known elite practicioners. When compared to Natale, who I've heard has done about 8,000 ablations, 40 a year just doesn't measure up. I don't mean to infer that he won't do a good job for you, but he just doesn't have the same level of experience.

I'm sure others will offer their insight into who might be best for you in your area.

In any event, I wish you well, my friend. Sending hopeful thoughts to you for NSR.

Sincerely,
Ken

Ken,

Glad to hear your ablation is holding out and thanks for the kind words. I should also mention that I had an ablation booked for June 2013 and in the month and a half before that, my a fib settled right down and I chickened out. Within 3-4 months after that it was worse than it had ever been and I decided to try daily meds.

Monty,

I can only speak for my experience, but it is very similar to most who travel to see Natale at St. David's Medical Center.

They are all true professionals. Natale's staff moves like clockwork. You have a nurse who is specifically assigned to you. I can pick up the phone or email her today and get an immediate response.

The experience at St. David's is equally fine. The staff was superb. I've never been treated or seen a family member treated any better in any hospital setting.

The procedure itself really wasn't that big of a deal. One night stay in the hospital and out by noon the next day. I hung around Austin in the hotel for the next 4 days at the request of Natale's staff, just in case I had any unusual problems. I didn't. Normal discomforts include some chest pain, a little swelling and or a little bloating.

After returning home, I had a few little early tachy episodes that I believe we related to digestive issues but those quickly subsided and have not recurred. All of the professionals say some blips are expected early on in the blanking period.

I will just reiterate what I'm sure you have read from Shannon many times-----try to do as much as you can to put the odds in your favor for having the best outcome. You can do that by selecting the best ablationist available to you.

Since I am a Florida native and still live in Florida, I can't offer you any help with your selection in your part of the world. However, I'm sure others on here can.

Best wishes.
Ken

Hello Montos,

I am going to offer you all the support and info I can. I travelled to Bordeaux for an ablation in 2005. I know a lot of people have heard my story and I tend to get a little long winded, so if you would like, I will send you a personal message. I have nothing but high praise for the Bordeaux team. In the past I offered and sent out numerous info packs and maps to fellow afibbers going to Bordeaux. Unfortunately I think I am out of maps, but I will double check. If you decide to go I will send you as much info as possible. Where in Canada do you live?

The only Dr. in Canada I would consider would be Dr. Khaykin and his team in South Lake regional Hospital located in Ontario. He is very highly recommended. I don't know how it works as far as medical coverage if travelling from another province.

Monty,

Your EP who does 40+ procedures a year is doing you a favor by refusing to do a second procedure on you. I wouldn't let him do the first procedure either. As Ken and others here have said, you only have one heart and you need to stack the odds in your favor by going to the most skilled EP you can find.

Best wishes,
Betty

Lou,

I live in Edmonton Alberta. I had talked to Adrian about this before as he is from Edmonton as well and we share a doctor. I should reconnect with him. I would be happy to hear whatever you can provide me with. Please feel free to PM me.

I think for me the critical point was that when I brought up the possibility of an ablation 3or 4 years ago my EP wanted me to try drugs first. So he warned me about serious complications like death. As well he said "there's a guy upstairs right now whose esophagus we had to remove". That did it for me. The last time I read the Bordeaux stats, in 20 years they had zero deaths and zero incidents of esophageal fistula.

I realize he was likely just trying to persuade me to try the meds first but I can't get past it.

Monty

Monty,

Shannon has previously published here the reference showing most ablations are done by low volume operators. The stats are not encouraging. I would certainly encourage you to go to Bordeaux or alternatively the best operator in Canada.

George

Montos, a little true story from one of our readers who made the same kind of bad idea mistake that your mind also naturally tried to bargain with .... especially with a history of backing out already :-). The mind can be your worst enemy if you let it, or best friend with some discrimination at such a time.

This nice fellow from his home in Hawaii had an ablation set with Dr Natale at San Francisco some 4 months hence, and yet the new ablation center in his city was just getting going and his local EP there was the head of the center and a very good and smart EP who I know and like very much as well too. But without a lot of experience in doing AFIB ablations every day.

This man who did not know San Fran very well nor had any friends or contacts there, figured quite logically that he would give the local EP and the rather new center there a shot at what seemed to be a rather straight forward paroxysmal case of AFIB and that if that did not work fully, he would still keep his Natale appointment and be able to fly over after his first blanking period was over, if there was still too many break throuhgs and have Dr Natale touch it all up and button everything down in a quick follow up procedure. But if he had good success in Hawaii then he saves the trips and added expenses etc ... so whats to lose right??

Sounded like a very smart and reasonable plan right? .... Well, this unfortunate gentleman woke up two days after his aborted ablation attempt in the cardiac intensive care units of the biggest medical center in city where he had had his ablation after having had his chest cracked open TWICE in the prior 48 hours with TWO mitral valve replacement procedures and still in rocking AFIB!!

Alas, the very well-meaning and no doubt mortified at what had happened EP, have inadvertently ripped out the mans mitral valve with, I suspect, the lasso mapping catheter ( though it could have been the ablation catheter too but the lasso was more likely what got snagged on the mitral valve inlet and then ripped out when it was not recognized that it was stuck. The first valve replacement job did not take either so had had to have a second chest opening and heart lung bypass procedure to redo the valve again.

He spent 6 months in cardiac rehab there before getting released and a bit over a year or year and a half later finally went to Austin to have Dr Natale do his index ablation properly as they never even got to any ablation work in his first tragic procedure.

Also, as Ive noted here often before, my very own older sister who has lived her entire life in Houston and does not like to travel any distances at all, also let a local cardiologist talk her into going to a new supposed new 'super star' ablationist who had just taken over the AFIB center at one of the largest hospital in Houston's world famous Medical center to save her from what seemed like the two far to go 3 hour drive from Houston to Austin.

I was back in Amsterdam at the time and was totally unaware of her decision to just get it done by this head of a huge hospital AFIB center cause how bad could he be, right to have been selected for that position??

To make matters even more frustrating and tragic, my sister had driven with her husband up to Austin to see me and meet Dr Natale when I had flown in from Amsterdam where I was living at the time, prior to my index ablation with him and I had made sure she well knew, and promised me, that should would only come to Austin and let Dr Natale fix her up as well when the time came, as she had persistent AFIB too along with several other co-morbidities and was 9 years older than I to boot.

Her persistent AFIB ablation with this head of a major hospital took 9 hours of torture with her rheumatoid arthritic back and body. And she was in worse symptomatic persistent AFIB afterward than when she went in! less than 6 months later she had a significant stroke while still on Coumadin and is bed ridden bot from her stroke and now progressed RA and still in persistent AFIB, though now rate controlled at least.

This doc apparently has harmed others too from what I have learned inside the industry since then, and he only had around 600 ablations under his belt when he attempted a complex symptomatic persistent AFIB ablation on my sister with her other issues as well!! Completely over his head and with disaster consequences for my sister to this day.
She has the most amazing good spirit and attitude still even though she has literally not been out of her bed for over 5 years straight now!

So Montos, go ahead if you wish, that odds are still good that you wont have the level of disaster outcome as noted in this two very similar cases as you are now considering following. But you are hugely stacking the deck not in your favor relative to letting Professors' Haissaguerre or Jais guide your procedure relative to settling for an easier and no doubt kind, thoughtful and well-meaning EP who who does less ablations in a year than Dr H and J do collectively every two weeks! And, like Dr Natale, a large percentage of there work is on a more challenging levels of AFIB.

The single most important decision you have to make in this whole game, Montos, is who do you partner up with for those golden hours guiding your ablation process to a successful completion with the least amount of time, work and procedures and with the greatest degree of safety, as you can possibly arrange for yourself.

And with the progression you have noted even since backing out in 2013, it has only likely made your own case somewhat more challenging now two years later, and could well have added more work needing to be done for a solid level of long term success. Thus, backing out again now, or going for convenience over quality with such a huge disparity between the two camps experience level when you are already set up to go with some of the world's best ablationists ... is not very handy up front decision making from all that I have learned over the years, I must say.

Though I also fully understand the thought process, for sure .. we all do! However, that is what we are here for too, to talk you off the edge of the cliff when some anxious 'what if' mental gymnastics is about to take you on a Swan dive off the high board into a much shallower pool.

Best of luck Montos on making the right call for yourself but you know my two cents on the matter.

Cheers!
Shannon



Edited 1 time(s). Last edit at 04/24/2015 10:39PM by Shannon.

Extremely well said, Shannon. I wholeheartedly concur.

Ken

Montos,

Have you investigated the possibilities of travelling to Ontario and having it done at Southlake? There is a waiting list with Drs. Verma and Khaykin but they are well worth the wait. It is worth investigating before going to the expense of the trip to Bordeaux.

I wish you all the best as you decide.

Marg

Shannon,

Well, that was certainly an honest opinion. I do appreciate that. The horror stories are bad but I think just having to go through all of this and not getting any better is bad as well. Even if it's no expense to myself, it's an invasive procedure that carries risks. Why go through all that for nothing?

I haven't been following things as closely this year as I had been in years prior. Are there any new studies talking about long-term outcomes?

Marg,

I've not looked into it recently but when I did two years ago I was told it wasn't possible.


Monty

Hi Montos,

Believe me, I was a king of procrastination and for years was determined to avoid an ablation and master this beast myself... And did a damn good job for over 5 years taking no cardiac drugs too just solid diet, key nutrient repletion, moderate but consistent exercise and yoga/ pranayama breathing exercise and other stress reduction methods.

I was never overweight, nor did I ever have Hypertension, sleep apnea, insulin resistance not ever smoked and no drinking for much of my life including during all
AFIB years and presently too.

Still, I eventually flipped into persistent AFIB by pushing things off a couple years too far for my own good.

That's the reason I'm been straight up with you and with your AFIB history.. ask yourself if not now then when? Are you prepared to wait until you flip into persistent AFIB, if so t least understand that is the likely outcome of further delay is all that I want you to appreciate here.

Yes there are risks with any medical procedure, but by choosing the added expense and effort of traveling to Bordeaux, you've just cut your risk for anything serious at all to truly vanishingly low levels. Yes, you might have some bruises on the groin for a week or two and some mild to moderate discomfort that's no big deal during deep breaths for a few days to few weeks at most, maybe some fatigue for a bit, but you can basically push way back on the back burner any concerns for any serious or lasting injury for going to these world renowned ablationist. It's not worth investing too much worry time Montos, regarding working with either of these two men at the helm of your ablation process ... Really!

Seriously, considering bailing from Bordeaux out of a real fear or concern of some terrible mistake happening to you there is a bad bet all around in my book. I've got a list of more realistic worries you can put ahead of that one that is a country mile long.

You would be safe with Dr. Khyatkin or Dr Verma a too at Southlake, but it's hard to beat going to the second and third most experienced ablationists in the world just a bit behind Dr. Natale in sheer number of skins on the wall but at the same overall level of expertise.

In any event, please don't take any of my comments personally either Montos ... I consider everyone here a friend and I would want any real friend of mine to share with me their unvarnished honest opinion as they saw it, if they felt I was considering a potentially costly decision.

Be well,
Shannon

PS Montos, one more thing I noticed in your last post when you asked "why go through all the expense and risk for nothing?" I don't recall every single report from the last 16 years here on the forum but I can tell you that I do not recall anyone ever saying that got anything other than an overall good experience at Bordeaux in all these years.. Why would you suddenly be the first after so much more experience that over the years?

Even if you require a touch up at some point, the odds of your AFIB burden being reduced substantially with an index ablation there are very high. Even from more average centers the lions share of patients report a net overall positive outcome, even if not full freedom from AFIB after a first procedure.

In any event, the point being the odds of you gaining nothing of real value from your experience at Bordeaux are very slim indeed at this stage of your obviously progressing.

Also, you ask about long term ablation stats and the best quality 10 full year 'prospective' study meaning it started why back in 2000 and included every paroxysmal patient at Cleveland Clinic ablated that year from Dec 2,000 to Jan 2,002 or just a year and a month and then following in real time for ten full years over 500 patients. At the end of 10 years 87% were in NSR and off all AAR drugs of the 530 some odd patients add Natale ablated a large majority of this group and the others were done by EPs at CC Natale was mentoring at the time.... Of the roughly 530 ablations that were done to get those results from over the full ten year period and 59% had one ablation with no need for a touch up and no need for AAR drugs and were in stable NSR at 10 years out.

That is an excellent outcome, 87% overall in NSR still at year ten and off drugs with 59% of those being 'one and done' over such a long time frame, especially when considering all of these index ablation a were in 2001 in the dark ages still of knowledge, experience and technology compared to now! But it's an apropos comparison for you Montos as you are set up now to visit EPs of similar elite experience and a good 14 years later along the rapidly evolving ablation learning curve. That should give you some reassurance that the odds of you wasting your time and money are slim indeed.

Best Shannon



Edited 3 time(s). Last edit at 04/25/2015 06:20AM by Shannon.

Monty,

I understand your feelings about not wanting an invasive procedure. When I was diagnosed with Afib, I was dead set against it. Unfortunately, my burden continued to grow and there was nothing I could do that had a positive impact on it. I truly believe ablation was my last chance.

My words are certainly not meant to pressure you nor offend. I'm only sharing my experience and the way I felt. There are others here that have been able to control their Afib with diet, supplementation and avoiding triggers. Sorry, I gave that 110%, but Afib didn't care. It grew like a cancer in me.

I too battled emotionally and cognitively along my afib journey, being initially totally against ablation, until I reached the point that I felt I had no other option. It is not an easy choice. There are pro's and con's to each side. In the end you are in charge of that decision. No one else can make it for you.

I wish there was a guarantee that ablation would solve your issues, but there isn't. I wanted that guarantee too. However, when I felt I had no other choice, and I certainly had the option to stay home in Florida and use the local, much less experienced practicioner, I took Shannon's advice and put myself in the absolute best spot for success by choosing Dr. Natale. Yes, it was inconvenient. Yes, it cost me extra money. However, it gave me the confidence that I was getting the best chance I had. So far, almost 3 months later, my heart is working fine and Afib free. Prior to the ablation, I was in almost constant day-time Afib with the only NSR I had coming during some sleeping hours. The emotional burden of feeling that erratic pulse in my carotid artery has been lifted. It really does feel like a significant weight has been lifted off of my shoulders.

No one can give you a guarantee. I know Shannon's examples weren't meant to pressure you to move forward with any procedure you aren't comfortable with.........but simply to illustrate that if you do move forward, try to get the best, most experienced ablationist you can.

I have to agree with BStevens comment above. If your local ablation doctor refuses up front to perform a second procedure, he probably doesn't really want to do the first one. That isn't the guy I would want working on my heart. Again, not meant to scare or offend........and in concert with George's reminder, the high volume centers have much better results than low volume centers.

I wish you the best of luck and well wishes, my friend. I know the struggle of the decision, having been through it myself. Perhaps I was lucky that the anti-arrhythmia meds didn't work for me..........they seemed to exacerbate my problem.........especially the high doses of Flecainide at the end. Those problems made my decision a little bit easier.

Sincerely,
Ken

Monty

You asked about the long term. I am now into my 13th year of sinus rhythm since ablation and touch up in Bordeaux in January 2003. I eat and drink whatever I like, I can sleep on my left side, I do moderate exercise three times a week, I scuba dive.

It gave me my life back.

Gill

Monty,
You know my story....I waited and stroked out!
I owe Shannon the boot in my ass as he constantly and was relentless in keeping me from backing out.....

Join the club and we will see you on the other side!

Just do it and don't look back...Best thing I ever did in my life!

McHale

McHale,

I do know your story and Gill's as well. Believe me the thought of that weighs heavily on my mind. Gill's story is nothing but inspiring, especially considering the advances in the procedure since then.

I've pretty much decided that I'm going to Bordeaux at this point and I thank everyone for their encouraging words. I will keep you all posted as events unfold.

Monty

Hi Monty,

A lot of people have gone to Bordeaux and had success. I did not have success.

If you are in Canada I would suggest Dr Allan Skanes in London Ontario at the LHSC. He has been doing ablations since 2000. My original attitude was treating a heart ablation like getting a cavity filled in a tooth. This is not the case. This a a very serious procedure regardless of what you hear.

Consider it carefully but I personally would stay in Canada. My opinion only. My last procedure in Bordeaux was a not good and my life has been shortened and with extreme pain.

Choose very carefully.

Keith

Keith,

I'm certainly not treating this like filling a tooth but yours is the first ever negative comment I have heard about Bordeaux.
Can you please elaborate? What happened, who did you see? What caused you to go to Bordeaux in the first place and when did you go?


Monty



Edited 2 time(s). Last edit at 04/26/2015 04:39PM by montos.

Keith - I'm very sorry to read you had an unfavorable experience at Bordeaux. Obviously, we would like to know more about your present situation if you would care to elaborate. Again, very sorry you are suffering.

Kind regards,
Jackie



For those in Canada who can travel to Toronto as an option, Atul Verma, MD - the electrophysiologist who was trained by Dr. Natale when he was at the Cleveland Clinic has been at Southlake Regional Hospital in Newmarket, Ontario for a number of years... well over 10 as I recall. Also on that team is Dr. Yaariv Khaykin who also trained in Cleveland 10 years ago.

Atul Verma, MD FRCPC, FHRS
Director, Heart Rhythm Program
Southlake Regional Health Centre
Professor of Medicine
University of Toronto

[www.southlakeregional.org]

[register.k-hrs.org]

Jackie

Monty I just sent you a PM with my phone number. My apology for missing your post earlier.

I have had a very good outcome from my journey to Bordeaux. If I had to do it again I would thoroughly search throughout Canada to see if there is an EP who may have developed a superior experience and success rate, and try to do it here. I sort of doubt that is the case yet, but I would again put the effort in, as you have done. If no one turned up to be a maestro here, I would return to Bordeaux.

Once you finally get to it, the approximate 2 hours you spend in the OR goes by in the blink of an eye.

What I can help you with is your timing and travel plans. The clinic is at Pessac which is half way between Bordeaux and Arcachon by train (about 30 minutes each way). Both are wonderful places, but if you are going to be there in late spring or summer you can't beat spending a little time convalescing on the beach at Arcachon.


Ron

Monty,

I went in 2006 and 2008. Consider support. If everything goes ok it is fine but you are back here and they are in France. I have to go now but I can talk to you later if you are interested.

I do not believe you hear about all the problems. People like myself tend not to post failures or do not want to talk about it. Much easier to talk about good stories.

Just another view.
keith

Keith,

I sent you a private message.

Monty

Monty, Just caught your post. I'm a bit late to the party but better late then never. It's a tough decision to make. On one hand you have the local guy who has a 60% success rate and you start thinking I could be one of the lucky ones. Why Not? If your flavour of afib is typical and the errant electrical signals are only coming from your pulmonary veins then it should be relatively easy to ablate with a circumnavigational ablation of said veins. Even if you have to go for a second procedure he is still local and the price is right (Free ). But what if your situation is more complicated as turned out in my case. My first ablation in 2010 held for about 16 hours. My second ablation in 2011 lasted for about three weeks then turned into flutter/afib. It was then that I decided to go to Bordeaux.

I had been an afibber since about 2002 and the afib burden got progressively worse over the years. I had been waiting ( perhaps foolishly) for the local guys to garner more experience. Seemed like a good Idea at the time. By the time of that first ablation I was pretty much persistent. (Can you say Difficult). So in reality my odds of success were probably a lot less than the 50% quoted me. I wanted a second ablation because I knew from reading the forum that it sometimes takes two ablations to achieve success. My Dr. agreed I needed a 2nd ablation but he would not be the one to do it as he was moving to Ontario, South Lake I believe. I asked him who was the best local Dr. and his answer was Lockwood. Your Dr. I believe, so I went to him. As you know that didn't work either.

So I made the decision to go to Bordeaux. Bordeaux did the trick. I have been beating normally ever since, for 3 years now. One thing I'd like to point out is that I did not get either of the masters, Haisaguerre or Jais but the equally competent, imho, Dr.Melize Hocini . Although a lot of the operation was fuzzy I can clearly remember towards the end of the operation when Dr. Hocini was having a hard time isolating a particularly toxic focus that was hiding in the coronary Sinus. They were trying and trying with fast pacing to get just the right spot but it was proving elusive. Finally there was the aha moment and burn and done thus demonstrating the diligence that is required to be a successful ablationist imho.

Were I able to do it over. I would go straight to bordeaux. Would it be one and done? Who knows, it still may require a second procedure considering I was persistent afib. The fact is that the best chance of having a one and done procedure is not here in Edmonton. It is in Bordeaux. After the bordeaux ablation I hung around France for another 3 weeks in case there was a relapse. They used to provide a second operation as quickly as possible but I would confirm that before going over.

Good luck with your decision. If you have any more questions you can pm me. I don't mind talking.

Cheers

Adrian

I think you should go to Bordeaux if you can afford it. As a surgeon(cataract), one of the things I pay close attention to is surgical time, or time under anesthesia, which can easily exceed 6 hours for an ablation. Reading this forum, and talking to my own patients with AF, it seems that the top tier EPs can commonly complete an ablation in under 3 hours, and sometimes less than two. Long anesthesia time can lead to fluid overload, electrolyte imbalances and even memory loss. As high volume practitioners, top tier physicians learn a fluidity of movement, efficient use of instruments and assistants and intense focus that leads to shorter procedure times. Your own procedure may take 5 hours, but its nice to know going in that the doctor has done it in 3.

very good point about that procedure time Lasik1. A really top tier elite ablationist is a fluid machine that flows from one movement to the next and us a joy to watch perform. I only wish they would do videos of our ablations so you could watch your EP at work ... Assuming you've got an expert working on you. 6 hrs for an ablation is still too common for sure for too many, but typically is a dead give away in most cases that they person is still very much in training and still climbing the experience ladder.

If a more experienced EP is in the room it usually means he has a fellow trainee doing much of the work while he observes and cracks the whip occasionally. Alas not infrequently the patient is not aware the guy with the local or regional name they thought was going to actual handle the catheters the whole time in your left atrium including trans-septal is not at all always the person doing such a job... But the big cheese is 'in the room' though little good that does when the trainee slips during a burn and snags a mitral valve with the lasso and tugs too hard before the main guy realizes what's going on.

Or motto is 'lets the other folks who don't know any better be the cannon fodder for the new trainees and fellows to practice on and make double sure which ever EP one chooses to do your ablation makes a verbal promise to you that only he or she will handle the catheters from

The moment of groin and/or jugular vein catheter access to the body until he pulls the catheters out of the body at the end of the procedure.

There are hundreds of thousands of patients who unfortunately never show the curiosity and initiative to seek out a site like ours to gain a better understanding of what the process entails.. They are the >81% of all Medicare ablations done in the U.S. By EPs doing less than 25 ablations a year and you would have to be pretty uninterested and unaware in your own Well fare to winded up with such a doc, so there is clearly no shortage of willing sheep to be lead to the trainees, and thank goodness none of our community has to be among that group.

Very good points on the anesthesia Lasik1 and best wishes on your upcoming procedure in Austin before long.
Shannon