Interventional Echocardiography CV Anesthesia

[Modanq]

Just a few links and references for those CV Anesthesiologists and residents thinking about CV Anesthesia. We should keep pushing the boundaries and our role into the cath lab. When I was a resident all I was told is that no one wants to do anesthesia cases in "offsite" locations. Well here we are - In my opinion, in addition to the ICU, the saving grace for anesthesiologists in a novel way to add value...

Links to Echocardiography Educational Videos

Symposium on Interventional Echocardiography and Decision-Making in Structural Heart Disease

Requirements for Interventional Echocardiographers

Structural heart. TAVR, Mitral Clip, Left Atrial Occlusion, EP PV Ablations, etc.

Thoughts. The tech side in 3D 4D is rapidly progressing.

---

Members don't see this ad.

 

[Modanq]

https://www.bidmc.org/-/media/files...tion.ashx?la=en&hash=ACC1B940DE312B506DC8E454

Figured I would post this here for those interested. CV anesthesiology Interventional Cardiology
Anyone bold enough to learn and try ICE on non EP cases.
Any ideas on using ICE in the cardiac OR?

 

[T-burglar]

I don’t know about the fellowship since this sub sub specialty is new and dynamic, but I do think that the cath/ep lab is a great way to be protected from mid levels. I just can’t picture CRNAs being allowed to operate in this new territory

 

[anbuitachi]

You mean crna independence? Cause all these cases are covered with crna in supervision model.

 

[T-burglar]

Yes independently

 

[anbuitachi]

If they can be independent in cardiac rooms then I don't see why not these cases. Basically I don't see how these protect us against them more than any other case requiring echo

 

[nimbus]

In some centers they have a dedicated cardiologist/echocardiographer doing the imaging. In others anesthesia provides imaging. Makes a huge difference in the demands of the case.

 

[T-burglar]

If they can be independent in cardiac rooms then I don't see why not these cases. Basically I don't see how these protect us against them more than any other case requiring echo

Their performance would be inadequate. These are cardiologists In high volume centers who know in depth interventional and diagnostic echocardiography, not dinosaur cardiac surgeons who still barely even know what they’re looking at in small town low volume heart hospitals

 

[T-burglar]

In some centers they have a dedicated cardiologist/echocardiographer doing the imaging. In others anesthesia provides imaging. Makes a huge difference.

This represents an opportunity for our subspecialty in my opinion. We are, in my opinion, the obvious choice for Perioperative echo

 

[drmwvr]

This represents an opportunity for our subspecialty in my opinion. We are, in my opinion, the obvious choice for Perioperative echo

There is the issue of "target fixation" I think, in cases like Watchmans and Mitraclip procedures. It's one thing for one person to do an anesthetic and echo exam for a cabg/valve or TAVR but where the procedure is essentially guided by echo, someone needs to pay attention to the anesthetic. Doesn't matter that it may even be the minority of patients that need undivided attention. Two people on these cases is very helpful, which is where the cardiologists come in.

 

[deleted171991]

The only question is who's cheaper: a cardiologist or a cardiac anesthesiologist? My money is on the former, so this will become ACT territory, too, as are all the other cath/EP procedures.

 

[drmwvr]

https://www.bidmc.org/-/media/files...tion.ashx?la=en&hash=ACC1B940DE312B506DC8E454

Figured I would post this here for those interested. CV anesthesiology Interventional Cardiology
Anyone bold enough to learn and try ICE on non EP cases.
Any ideas on using ICE in the cardiac OR?

I could see it for TAVR's (especially for awake ones) but not for open valve replacement. Seems to add a layer of complexity that doesn't provide any significant benefit over TEE. And I would think that it complicates running retrograde cardioplegia.

 

[nlax30]

I see the value in TEE. For our extractions in the OR we routinely have CV anesthesia manage the TEE and it’s great.

For structural cases (TAVR, Mitraclip, LAA occlusion, etc...) that are more image guided intensive then the only issue I see (as mentioned above) is that it really needs a dedicated imager, whether a cardiologist of CV anesthesia (less an issue in TAVR) in addition to the anesthesiologist. I would think too much for one person to handle unless the mid level was handling the anesthesia portion and anesthesiologist then handled the imaged.

I see less value in ICE. I use it routinely in EP procedures (basically an essential part of our workflow now) but it’s something I’m managing there on the field. Currently it’s a single plane so not as versatile as TEE and I don’t see how you guys would use it in its current form.

 

[T-burglar]

The only question is who's cheaper: a cardiologist or a cardiac anesthesiologist? My money is on the former, so this will become ACT territory, too, as are all the other cath/EP procedures.

Currently it’s cheaper for CT anesthesia to handle it because the interventional echo code is not being reimbursed separately from the the entire procedure. So to have a cardiologist in there not getting paid and not doing clinic or echo lab work that actually is reimbursed is a loss for cardiology.

Even when it becomes reimbursed separately (it will), it will still be worse reimbursement for the cardiologist to give up clinic and echo lab to sit in the procedure suite. It will however be extra revenue for CT anes services with the foresight to take over this role.

 

[Mr.S]

I don’t know about the fellowship since this sub sub specialty is new and dynamic, but I do think that the cath/ep lab is a great way to be protected from mid levels. I just can’t picture CRNAs being allowed to operate in this new territory

CRNAs will be involved with these cases. Unless The Anesthesiologist wants to cover this case on his/her own.

IF you read the Diagnostic and INterventional Cardiologist website they say it is NOT worth it to staff these cases with a dedicated cardiologist to do the echo when they can do 25 in the lab. They say it aint worth it. I kinda agree with them. Enter Anesthesiologist. "we"ll do it"

 

[kidthor]

I'm surprised nobody yet has suggested this fellowship is a waste of time.

You want to do 6mo-12mo of a non-accredited fellowship to be a lackey who gets paid nothing extra ultimately. Not to mention there's no board certification. And then you'll be blamed when the cardiologist messes up the procedure and you then crash onto bypass?

No thanks.

If anything just do a proper cardiac anesthesia fellowship?!

 

[Modanq]

I'm surprised nobody yet has suggested this fellowship is a waste of time.

You want to do 6mo-12mo of a non-accredited fellowship to be a lackey who gets paid nothing extra ultimately. Not to mention there's no board certification. And then you'll be blamed when the cardiologist messes up the procedure and you then crash onto bypass?

No thanks.

If anything just do a proper cardiac anesthesia fellowship?!

Yeah, I agree with you re: $$ but niche programs like this are geared towards expanding scope and footprint. If we all shy away from getting our hands dirty or "blamed" might as well be a nurse. Responsibility what's that...

 

[AdmiralChz]

I would argue a fresh CV Anesthesia graduate should be comfortable doing most of this stuff. It’s a little tricky to do it all while doing the anesthetic as well, and probably suboptimal if measurements haven’t been done ahead of time (e.g. for the Watchman). Many academic centers have a cardiologist who does the TEE as these cases are nearly exclusively done in the cath lab.

 

[Modanq]

I would argue a fresh CV Anesthesia graduate should be comfortable doing most of this stuff. It’s a little tricky to do it all while doing the anesthetic as well, and probably suboptimal if measurements haven’t been done ahead of time (e.g. for the Watchman). Many academic centers have a cardiologist who does the TEE as these cases are nearly exclusively done in the cath lab.

I'm not old enough to remember the conversations/negativity Shanewise et al. Faced when he introduced TEE into the cardiac OR.

No one questions when our rickety old timey surgeon who only trained open starts up on the Robot but everyone gets alarmed when we anesthesiologists actually join the Interventional team and make decisions on Valve placement.

It's open for debate but whats our role again? Turn the iso on and off?

 

[kidthor]

but everyone gets alarmed when we anesthesiologists actually join the Interventional team and make decisions on Valve placement.

But are you actually making decisions, and do you get paid for those decisions? Or are you just giving (free) information to the interventional cardiologist who's making a TON off their procedure and you're just billing like you would for any other procedure? And, isn't this all solidly in the scope of a proper cardiac anesthesiologist anyway?

 

[Modanq]

But are you actually making decisions, and do you get paid for those decisions? Or are you just giving (free) information to the interventional cardiologist who's making a TON off their procedure and you're just billing like you would for any other procedure? And, isn't this all solidly in the scope of a proper cardiac anesthesiologist anyway?

Agree. Def we need to work on mechanisms on reimbursement for the interventional TEE. But this time we cant be left off the table when the pie is cut.

 

[deleted171991]

If the interventional TEE will be worth more than peanuts, it will be done by cardiologists. If it's peanuts, they will leave it to cardiac anesthesiologists. Either way, it's dumb to do a fellowship just for it.

People who want job safety should become the best anesthesiologists they can (which also includes becoming the best butt-kissers they can - a must nowadays), not do fellowships (with the exception of ACGME cardiac). Also, pain (and CCM for a while) will offer job security outside of the OR.

 

[kidthor]

Agree. Def we need to work on mechanisms on reimbursement for the interventional TEE. But this time we cant be left off the table when the pie is cut.

I def agree with you. We need to boost reimbursement and recognition for our services, including interventional TEE. If we are providing mission-critical input then we need to be paid accordingly (and we are currently letting everyone else leech reimbursement from us).

 

[itwasalladream]

It's unfortunate. I can do TEE on an 8hr multiple valve case with LV/RV failure, eval pre/post valve function with hours of ongoing monitoring and management decisions that may affect the patient for the rest of their life, and collect about $120-150 for the TEE. The same billing code a cardiologist gets for a 5 minute outpatient exam.

Our interventional TEE billing code seems to only get us marginally more - around $215 or so.

Meh.

 

[T-burglar]

Is it worth a ton of money? Not at present. But 93355 is a 7 unit code that your department could collect if you can figure out how to capture this work. We negotiated with our hospital to fund a “float” anesthesiologist position for example so we are getting well paid to do this

 

[AdmiralChz]

It's unfortunate. I can do TEE on an 8hr multiple valve case with LV/RV failure, eval pre/post valve function with hours of ongoing monitoring and management decisions that may affect the patient for the rest of their life, and collect about $120-150 for the TEE. The same billing code a cardiologist gets for a 5 minute outpatient exam.

Our interventional TEE billing code seems to only get us marginally more - around $215 or so.

Meh.

Nearly exactly what we get. Since I don’t see this reimbursement increasing - AT ALL - in the immediate future, we don’t get too unhappy when the cardiologists want to do the structural exam. We still bill for placement, which apparently gets us something like $50-75.

Maybe we would feel differently if we did a whole boatload of cases and it would add up over time, but we only do a handful each month so for now it definitely ain’t worth it and those cases don’t require an advanced TEE person otherwise (watchman, PFO closure).

 

[Modanq]

93355 is the code that was created for this. Also useful to watch ASE and help support and make anesthesiologists presence felt there. There should be different codes for different procedures tavr versus mitral clip

 

[Psai]

Nearly exactly what we get. Since I don’t see this reimbursement increasing - AT ALL - in the immediate future, we don’t get too unhappy when the cardiologists want to do the structural exam. We still bill for placement, which apparently gets us something like $50-75.

Maybe we would feel differently if we did a whole boatload of cases and it would add up over time, but we only do a handful each month so for now it definitely ain’t worth it and those cases don’t require an advanced TEE person otherwise (watchman, PFO closure).

Placing it gives you half as much as doing the entire exam for the whole case? goddamn

 

[deleted171991]

Placing it gives you half as much as doing the entire exam for the whole case? goddamn

You must have never seen one of these echoboard-certified cardiologists wrestle with placing a TEE probe for 10-15 minutes.

 

[kidthor]

You must have never seen one of these echoboard-certified cardiologists wrestle with placing a TEE probe for 10-15 minutes.

They can make TEE insertion into the biggest production ever. I remember them asking for the table, head, ETT, and drapes to moved all over... just to get it in - and then still had to ask for help.

Don't get me started on the rest of the exam.

Funny that we make simple things look easy. And others make simple things look hard (and then get more respect and money for it).

 

[Psai]

You must have never seen one of these echoboard-certified cardiologists wrestle with placing a TEE probe for 10-15 minutes.

I mean I have but I'm no pro at placing them without a blade although my attendings make it look so damn easy

 

[anes121508]

Is it worth a ton of money? Not at present. But 93355 is a 7 unit code that your department could collect if you can figure out how to capture this work. We negotiated with our hospital to fund a “float” anesthesiologist position for example so we are getting well paid to do this

ASE newsletter when i googled the code:
It is important to note that there are edits in place which do not permit the reporting of Interventional TEE (CPT code 93355) with anesthesia services. CMS has indicated that their position is that the delivery of the diagnostic and interventional periods of the 93355 TEE service are not to be performed simultaneously with the anesthesia service. The work involved in performing interventional TEE is provided in real time and requires the physical manipulation of the TEE probe by the provider responsible for the probe placement and management of the TEE.


So, it seems as though CMS does not think we should be providing continual guidance of the clip, while delivering the anesthetic. I'd assume this would be if you were doing this case solo. What if you are covering it with the CRNA?

Can someone please clarify the reimbursement rules and the amounts for structural heart guidance?

For those of you who are doing solo cases and doing the TEE for structural, what has your experience been?

In terms of the fellowship, thats nice, but that should be included in the CT fellowship.

 

[anes121508]

Is it worth a ton of money? Not at present. But 93355 is a 7 unit code that your department could collect if you can figure out how to capture this work. We negotiated with our hospital to fund a “float” anesthesiologist position for example so we are getting well paid to do this

can you elaborate on the "float" position? I'm assuming this is how you get to bill for it. What did you tell the hospital to get funded for this? Tips on this negotiation? By well paid to do this, do you mean you are the float person and making your normal hourly wage?

I ask, because I'd like to figure out a way to do the TEE for these cases. My group currently covers 3:1. I asked to possibly do the case solo, but was told we don't typically put docs in rooms. Currently cards does the tee with the tech. Can't possibly be cost effective. I'm young so I don't have tons of experience with the financial aspect of things. If you were me, how would you build the argument to either do the case solo, or create a float position? How did you do it?

 

[T-burglar]

Correct you can’t submit 93355 if you are anesthetizing as well. I BELIEVE that means you essentaially need two physicians (can’t be supervising the anesthetizer either). We had our heart surgeons tell the administration they wanted an anesthesiologist free and dedicated to bouncing around to cardiac ORs and the cath lab for TEEs and that the position needed to pay something similar to an average days work. Our surgeons have the clout to demand some things.

These types of negotiations are helped by getting the other services to comfirm the need of desirability

 

[itwasalladream]

So the regular TEE codes 93312 + color and spectral doppler modifiers can still be billed and collected while doing TAVR. So when there's not an extra anesthesiologist to do the exam, I do the anesthesia and the TAVR study. It's not hard, and I believe a number of places do this. If we have an extra person available they come in and do the study, billing the "structural code" 93355 because it collects a bit more. The anesthesiologist should still be able to bill for probe insertion in this situation. We have not had any payments denied that I'm aware of, doing it this way.

At our hospital the cardiologists aren't interested in the TEEs, so it's just a matter of what costs more: extra anesthesiologist around to bill 93355, or take the small hit in reimbursement and do TEE/anesthesia with one MD, billing 93312.

That being said - my opinion is that this works fine with TAVR but can be difficult with other, more TEE intensive, procedures depending on the operators. Watchman, PVL closure, mitraclip etc. Your experience may vary.

 

[anes121508]

So the regular TEE codes 93312 + color and spectral doppler modifiers can still be billed and collected while doing TAVR. So when there's not an extra anesthesiologist to do the exam, I do the anesthesia and the TAVR study. It's not hard, and I believe a number of places do this. If we have an extra person available they come in and do the study, billing the "structural code" 93355 because it collects a bit more. The anesthesiologist should still be able to bill for probe insertion in this situation. We have not had any payments denied that I'm aware of, doing it this way.

At our hospital the cardiologists aren't interested in the TEEs, so it's just a matter of what costs more: extra anesthesiologist around to bill 93355, or take the small hit in reimbursement and do TEE/anesthesia with one MD, billing 93312.

That being said - my opinion is that this works fine with TAVR but can be difficult with other, more TEE intensive, procedures depending on the operators. Watchman, PVL closure, mitraclip etc. Your experience may vary.

You are doing the tte for the tavr?

Agree, pvl, watchman, clips ect are more work than tavr. Although in general the hemodynamics typically are boring for those cases which allows the echo guidance to be manageable.

 

[anes121508]

Correct you can’t submit 93355 if you are anesthetizing as well. I BELIEVE that means you essentaially need two physicians (can’t be supervising the anesthetizer either). We had our heart surgeons tell the administration they wanted an anesthesiologist free and dedicated to bouncing around to cardiac ORs and the cath lab for TEEs and that the position needed to pay something similar to an average days work. Our surgeons have the clout to demand some things.

These types of negotiations are helped by getting the other services to comfirm the need of desirability

Amazing because that’s how things work here. If ct surgery supports the request, then hospital admin gets it done.

Why though, do the ct surgeons want a guy floating for tee? Why not just the doc covering the room? Not everyone is tee certified on the “heart team”?

 

[itwasalladream]

You are doing the tte for the tavr?

Agree, pvl, watchman, clips ect are more work than tavr. Although in general the hemodynamics typically are boring for those cases which allows the echo guidance to be manageable.

TEE yes. TTE no.

 

[Modanq]

From the May 2019 consensus guidelines on valvular disease. JACC 2019

“As treatment options rapidly expand for VHD, a new specialty of interventional echocardiography is emerging (52). Interventional echocardiographers blend a sophisti- cated knowledge of echocardiography with clinical expertise and can help guide management decisions at the point of intervention. They have become integral to the high performance of any MDT, especially at Compre- hensive (Level I) Centers. The interventional echocardi- ographer is a critical participant in select valve cases (e.g., transcatheter mitral valve repair and repair of para- valvular leaks). Effectiveness in this role requires an in dividual who has regular involvement in these procedures and thus is familiar with the devices and procedural steps, is competent to provide interventionalists with imaging guidance for transcatheter procedures, understands how echocardiography can help avoid or identify procedural complications, recognizes the unique echocardiographic characteristics of transcatheter devices and delivery sys- tems, is proficient with 3D imaging, and understands the treatment goals of transcatheter valve procedures.
Although it is important that advanced imaging expertise be readily available at Comprehensive (Level I) and Primary (Level II) Valve Centers, personnel repre- senting these imaging areas may vary between centers. Both cardiologists and cardiac anesthesiologists should have the knowledge and skills to perform and interpret procedure-based transesophageal echocardiograms, particularly if they are board certified in echocardiogra- phy. Cardiovascular imaging specialists provide advanced CT services in most institutions.”


CV Anesthesiologists ****
Biggest take home is we should own this....
Some whispers going on that interventional TEE may get procedural reimbursement splitting the cost of the procedure since it takes hours to complete and cards can’t fork over an imager for the whole day. We are in the room and now the New ASE president is an anesthesiologist....we should learn quickly.

 

[Modanq]

We should post more resources so that the future anesthesiologists - residents and medical students realize what CV anesthesia brings to the table and might peak interest in future applicants in an emerging perioperative and periprocedural imaging area including interventional imaging.

 

[Section31]

I personally have been trained to do these cases at my institution. Abbott paid for me to attend their MitraClip course etc. I’m the dedicated echocardographer. Even my partners are not acceptable for the cardiologists. It has to be me. While it seems like a honor, there are logistical issues. It’s really really hard to supervise multiple rooms with that set up. And it can get dreadfully boring. I also don’t think we get reimbursed very well for the echo portion. It’s only a few hundred bucks extra for HOURS of work. But I do feel accomplished while doing them. It’s really the only time I feel I’m providing unique expertise.

Then again some of my partners resent me for having these skills when they do not.

 

[Section31]

I personally have been trained to do these cases at my institution. Abbott paid for me to attend their MitraClip course etc. I’m the dedicated echocardographer. Even my partners are not acceptable for the cardiologists. It has to be me. While it seems like a honor, there are logistical issues. It’s really really hard to supervise multiple rooms with that set up. And it can get dreadfully boring.

I'm surprised nobody yet has suggested this fellowship is a waste of time.

You want to do 6mo-12mo of a non-accredited fellowship to be a lackey who gets paid nothing extra ultimately. Not to mention there's no board certification. And then you'll be blamed when the cardiologist messes up the procedure and you then crash onto bypass?

No thanks.

If anything just do a proper cardiac anesthesia fellowship?!

There’s no such thing as a “proper” cardiac fellowship. And I say that as someone who did a cardiac fellowship. We have no board exam. Only the Advanced Echo certification. You get that just in time to realize the Basic certification can bill for echo at the same rates. So you lost $300k and a year of youth for nothing. Nothing. Fellowships are a scam. All of them.

 

[vector2]

I personally have been trained to do these cases at my institution. Abbott paid for me to attend their MitraClip course etc. I’m the dedicated echocardographer. Even my partners are not acceptable for the cardiologists. It has to be me. While it seems like a honor, there are logistical issues. It’s really really hard to supervise multiple rooms with that set up. And it can get dreadfully boring. I also don’t think we get reimbursed very well for the echo portion. It’s only a few hundred bucks extra for HOURS of work. But I do feel accomplished while doing them. It’s really the only time I feel I’m providing unique expertise.

Then again some of my partners resent me for having these skills when they do not.

Wait, are your partners (who they’re not requesting) also cardiac trained? We recently started doing mitraclips and honestly I think any PTE certified person could staff the case since the rep really requested just about 5 views (septum in the 4ch and bicaval, MV in the commisural, AV long, and 3D en face). Evaluating a valve and knowing eligibility and exclusion criteria for mitraclip is def more complex, but usually that legwork has been done by the time they get to us.

 

[DM27]

Partners may be less comfortable with 3D. Anyone who is PTE certified should be able to do a mitraclip as long as they have a good understanding of acquiring and interpreting 3D images (many otherwise good older cardiac attendings I've worked with are not) and know enough about the procedure to be able to make relevant adjustments to the image. I've found that a lot of the hand-holding from the echocardiographer's end comes when they are making the transseptal puncture and using the guidance system, which requires a lot of comfort with dynamic use of 3D.

 

[pgg]

There’s no such thing as a “proper” cardiac fellowship. And I say that as someone who did a cardiac fellowship. We have no board exam. Only the Advanced Echo certification. You get that just in time to realize the Basic certification can bill for echo at the same rates. So you lost $300k and a year of youth for nothing. Nothing. Fellowships are a scam. All of them.

If all you got out of your cardiac fellowship was a slip of paper from NBE, you went to a lousy fellowship program.

 

[Section31]

If all you got out of your cardiac fellowship was a slip of paper from NBE, you went to a lousy fellowship program.

I went to one of the best and worked by butt off for a year. It was exhausting. I’m simply jaded and bitter. Probably best not to listen to me.

 

[Section31]

Wait, are your partners (who they’re not requesting) also cardiac trained? We recently started doing mitraclips and honestly I think any PTE certified person could staff the case since the rep really requested just about 5 views (septum in the 4ch and bicaval, MV in the commisural, AV long, and 3D en face). Evaluating a valve and knowing eligibility and exclusion criteria for mitraclip is def more complex, but usually that legwork has been done by the time they get to us.

No, my partners are not formally cardiac trained. One is grandfathered. They want me because of my cardiac training and echo certification.

So I guess my very existence undermines my previous argument that fellowships are a scam. That being said, anyone can learn echo and do exactly what I do.

The only views necessary are commissural (to establish medial-lateral), ME LAX (to establish anterior posterior), Bicaval (for septal puncture), AV SAX (to make sure you don’t puncture aorta), and 3D mitral views to visualize clips. Transgastric views are rarely necessary.

 

[Man o War]

There’s no such thing as a “proper” cardiac fellowship. And I say that as someone who did a cardiac fellowship. We have no board exam. Only the Advanced Echo certification. You get that just in time to realize the Basic certification can bill for echo at the same rates. So you lost $300k and a year of youth for nothing. Nothing. Fellowships are a scam. All of them.

Even if the year of cardiac fellowship was a scam(I don’t think it was for me based on my experience), hospitals are trending toward requiring advanced echo cert to be a cardiac guy/gal. The only way to get that as a currently graduating grad is the fellowship.
You’re limiting your options for doing hearts if you don’t do the fellowship.

 

[Section31]

Even if the year of cardiac fellowship was a scam(I don’t think it was for me based on my experience), hospitals are trending toward requiring advanced echo cert to be a cardiac guy/gal. The only way to get that as a currently graduating grad is the fellowship.
You’re limiting your options for doing hearts if you don’t do the fellowship.

That might be true for guys coming out of training. But my experience has shown me that the only thing you need to prove you can do hearts is a recent track record of doing hearts.

 

[Man o War]

That might be true for guys coming out of training. But my experience has shown me that the only thing you need to prove you can do hearts is a recent track record of doing hearts.

In some cases with some docs I agree, but at the end of the day the hospital decides what they want for credentialing. When I was interviewing, a very good established private group had to displace a bunch of their long time cardiac guys because they didn’t have the certification and would not or could not get it. I didn’t interview anywhere that had non echo certified docs doing hearts.