Intro: Welcome to Pediatric Voices, Duke Children's podcast about kids healthcare. Now, here's our host, Dr. Angelo Milazzo.

Dr Angelo Milazzo (Host): Hello and welcome to Pediatric Voices, a podcast that dives into conversation with the people who make up the Duke Children's healthcare team. I'm Dr. Angelo Milazzo, a pediatric cardiologist and a Professor of Pediatrics at Duke Children's and one of the hosts of the podcast. I'm here to bring you insights about timely topics in children's health from my expert friends and colleagues.

On this episode of Pediatric Voices, let's look at what's happening in the field of pediatric heart surgery. This, of course, is a topic which is near and dear to me in my work as a cardiologist. And one of the great things about my practice here at Duke Children's is that my cardiology partners and I are fortunate, because we get to work with a team of incredible surgeons, critical care specialists, anesthesiologists, nurses, therapists and others. And together, we are organized into what we call the Duke Pediatric and Congenital Heart Center. And that center manages the work involved in caring for children with heart disease from before the time they're born, through the complicated surgical procedures they undergo, through their hospitalizations and recovery, and then across the span of their childhood and beyond.

I've mentioned in other episodes that today we have the technology to treat children born with all forms of congenital and acquired heart disease. Today, we can offer operations on the most complicated cases with incredible results. And in virtually all of our cases, patients go on to lead happy, healthy, productive and active lives.

So today, I have the ideal colleague and expert to discuss the practice of pediatric cardiothoracic surgery, in other words, pediatric heart surgery. Today, I'll be talking with Dr. Joe Turek. Dr. Turek is a pediatric heart surgeon, so that means he's trained in general surgery, in heart surgery, and then specifically in pediatric heart surgery. He also has specific expertise in heart transplant surgery, and we'll get into that in our conversation today.

Dr. Turek is an Associate Professor of Pediatrics in the Duke University School of Medicine here in sunny Durham, North Carolina. Dr. Turek serves as the Chief of Pediatric Cardiac Surgery, as well as the Executive Co-Director of our Pediatric and Congenital Heart Center. His career has been marked by innovations and advances in the field of Pediatric Heart Surgery, including the world's first co-transplant of both heart and thymus tissue. And he has also pioneered a novel technique known as partial heart transplant. And again, we're going to dive deeply into that today and hear more about that from Dr. Turek.

So without any further ado, welcome Dr. Turek. Joe, it's a great pleasure to have you here on the podcast. You're a busy man and it took a while to get you on. So I'm very excited to have the opportunity to talk today.

Dr Joseph Turek: Oh, thanks, Angelo. I've been excited about doing this.

Host: Joe, I like to start with the origin story. So, tell me how you first got interested in surgery, and then how did you get interested in pediatric heart surgery?

Dr Joseph Turek: Well, I've always been fascinated with science. And I wanted to figure out how I could get more into the field of medicine. That's really hard to do when you're a high school student, but I found some laboratories that they allowed me to work in when I was as early as a sophomore in high school. And when I got in those laboratories, I realized I didn't have the scientific background in order to necessarily understand what all the experiments were.

And so, they kind of put me in the animal surgery portion of things. And what they found very quickly is that I was actually pretty good with my hands, and I was able to do all these very complex procedures, as we were studying different kinds of health-related challenges. And so at that point, that really set me on this track that I wanted to be a surgeon. I didn't know what kind of surgeon at that point, but I knew I wanted to be a surgeon.

Host: So, your interest started really early, and that seems to be common. You know, all the guests that I've had on the show so far have pointed to these really early experiences. So, it sounds like you would say that your inspiration and your aptitude for surgery was identified at a very early stage in your career.

Dr Joseph Turek: Quite early, yes.

Host: So, Joe, I want to get into the topic today. I want to explain, introduce pediatric heart surgery. But I also want to make sure we talk about some of the game-changing innovations that you and your team have brought to this field. But let's start with an introduction. How would you bring this topic to our audience?

Dr Joseph Turek: Pediatric heart surgery has been around for about 60 years. We did a lot of procedures prior to that that were not using the heart-lung machine. But by and large, the advent of a machine that would support a child's heart and lungs while you're able to do all of these complex cardiac repairs is really what made this field take off. And so, that happened about 60 years ago or so, and we've really come a long way with pediatric heart surgery over that last 60 years. There were many conditions when this first started out and even up until the mid-'80s. They were considered universally fatal if a child was born with that type of congenital heart disease.

And now, we've gotten to the point where we can take even those operations that you could not leave the hospital with your child. And now, we can make it such that you can take your child home, and not just take them home, but they can live a normal active life. And I think that's the real success story of what we've been able to do with congenital heart surgery.

Host: I agree. I think that's really well said. And it's interesting if I think about my own experience with this field. When I was in medical school in the '90s, there were very few operations that could be offered to the more complicated patients. And the sad reality is that we didn't have options for a lot of those kids. And in many cases, families were told there's nothing we can do. There's an opportunity for comfort care. You can take your baby home and let nature take its course. And that was a really, really devastating experience for a lot of families. And then, the first operations began to be performed in various centers of expertise across the US. And then, very quickly, things started to change. I think it's interesting that in 20, 30 years, we've really revolutionized the care of these patients.

Dr Joseph Turek: Yeah. It's really been incredible. And I think that we'll talk later on this in the show, but when we start to talk about this new innovation, this partial heart transplantation, that is for a population of children that really had no option before this. And so, this is just another iteration of how we're developing and making it such that a child can actually live a long, happy life with innovations in pediatric heart surgery. So, we're not done. We're still innovating and we're still pushing things along.

Host: Joe, let's talk a little bit about your work here at Duke and in the Duke Pediatric and Congenital Heart Center and talk a little bit about how the work here is really impacting the care of kids both locally and in the region and even broader perspective on that.

Dr Joseph Turek: Right. And, you know, we both feel this way, Angelo, but, you know, I think we know that our entire team, we have immense pride in what we've been able to do as a pediatric and congenital heart center here at Duke. Our team, and you laid out a number of those groups within our team, the nurses, the anesthesiologists, the surgeons, the cardiologists, the intensive care doctors, the perfusionists, I mean, I can't name them all. There's so many people. There are about 250 to 300 individuals that make up our Duke Pediatric and Congenital Heart Center. And what we've been able to do with this center since it was founded about six years ago is become the number two program in the country based upon the US News and World Report rankings. And there's a reason for that.

When you look at the outcomes that we've been able to have because of this high functioning team across the last four years, they're the best outcomes for congenital heart surgery in America. And I think another thing that has really pushed forward our ability to offer great care to kids is the fact that we're also really on the cutting edge of innovation across a whole number of aspects.

So, we're doing great work, we're doing high quality work, and we're doing innovative work, which is really special. And to be able to have that here in the state of North Carolina is special for the kids of our state.

Host: One thing our audience may not appreciate or be familiar with is the wide variety of different conditions that we treat. Some congenital heart defects are minor and straightforward and don't even require treatment. But many are complicated, life-threatening, some are life-threatening very early in life. Some become impactful on health later in a child's life. Can you talk a little bit about the breadth of the conditions that we treat and your approach to the different types of congenital heart disease?

Dr Joseph Turek: Yeah, absolutely. I mean, this is one of the reasons I went into this field. I went into pediatric heart surgery. When I finally became enamored with heart surgery, I realized that pediatric heart surgery has the most variety of any specialty out there. In a month, I won't do the same case twice. There's so much differences across the board of congenital defects.

The other reason I went into it is it really is a challenging specialty. It challenges your mind and it challenges your dexterity and ability to do these operations. And I believe it's the most challenging of the surgical specialties that are out there. When you think about it, you're operating on a heart the size of a strawberry, and you're doing these complicated intracardiac repairs on that tiny little heart. So, the variety, the challenge, those are things that really, really were a draw for me to do this work.

In addition to that, I can't imagine a more rewarding specialty. And I tried to imagine a more rewarding specialty. When I was in training, I thought, "Oh, there's got to be something that I can like just as much as this." But I couldn't find it. I mean, when you look at it and you look at modern pediatric heart surgery, you can operate on newborn babies and do operations that ultimately can allow that child to live a normal life and a normal life longevity. I mean, imagine that. I mean, talk about something rewarding.

And then, the other piece I like about that is that pediatric heart surgery is a big deal. And I don't go into an operation ever thinking it's not a big deal. Because even though I might have done this operation hundreds of times, it's the first time for that family, that they're going through that. And so, it puts you in a position as a pediatric heart surgeon to be able to really comfort a family. And I think that's something that a lot of people aren't able to do in their life and to actually feel that responsibility is really a gift in this field.

 So, I enjoy the whole variety of pediatric heart surgery. You know, some of the cases, we do will operate on a child within their first 24 hours of life for some corrective operations. There are other operations that are much more elective and maybe they're done prior to the child going to school, just to be able to prevent any of the complications down the road. And then, we call ourselves congenital heart surgeons in addition to pediatric heart surgeons, because we operate on anything that's within your genes. So if you were born with a heart condition, and let's say you're 60 years old now, I could still be your surgeon, because that is the specialty with which we've trained, as congenital heart surgeons.

Host: I love the way you put that, and what you've said about your perspective on cardiac surgery absolutely aligns with my perspective as a pediatric cardiologist. I chose the field for the same reasons you did. I enjoy the complexity, the incredible variety of things that we see and I feel like, you know, now, well into my career, I'm still learning. I'm still seeing things that I haven't encountered before, or at least variations of things that I haven't encountered. And that's what makes our field, I think, endlessly fascinating. I like the anatomy of it. I like the physiology of it. You know, we get to be experts in the way the heart works in so many different levels, whether it's the electrical activity of the heart or the mechanical activity of the heart. It's great for people who like the way things are put together, the way things are taken apart and put back together again.

And the other thing I would say is to show our audience a little bit behind the curtain, what we do is a partnership. So, the cardiologists work together with the heart surgeons to make diagnoses, to offer treatments and then to continue to follow these kids throughout their lives. Because as you said, some of these children require additional treatment, but in most cases these children do really well and go on to lead very, very normal lives, normal energy level, can attend school, can do the things that you expect children to do. And it becomes a really satisfying field in that respect. So, I think I was drawn to it for the same reasons that you've articulated today. So, I really appreciate your answer.

Joe, let's talk a little bit about some of the breakthroughs that are happening. I think one of the amazing things about being in a place like Duke is we can go from the lab to the bedside, from experiment to actual innovation and directly impacting the care of patients based on the ideas that you come up with as a scientist, because you are in addition to being a surgeon also a scientist who has done research and has brought those research experiences and those research innovations directly into the way you care for your patients. So, can you elaborate on some of the innovative things that you're doing today with your team?

Dr Joseph Turek: When I approach patients with congenital heart disease, the first thing that pops into my head is how can we do it better? And how can we improve on where we are? And you learn all of these different operations and techniques over years and years of training from the time I Graduated from high school until I was a pediatric heart surgeon on faculty. At the time, it was at the University of Iowa. It was 17 years. It was a 17-year period of time in there where I was learning all of this. So, there's a lot that you have to learn. But then once you learn it, one of the things that really gets me up in the morning and gets me excited is how can I do better? How can we advance this field? How can we make the lives of these kids better than they are today?

And so, what I think about is, is there a problem with this current operation? So, one of the examples is the Norwood operation. So, one of our highest risk cases that we do are children that are born with half of a heart. The first operation that we do for those children in their first week of life is a procedure in which we kind of reroute the plumbing of the heart, as we'd say, in order to be able to, allow that one side of the heart to do the work of two sides of the heart. And it's our highest mortality operation that's out there for congenital heart disease. And I felt like maybe there was something we could do to make that better. And so, we developed a technique, and we call it Star Perfusion, where we basically give blood flow to the entire body. While we're doing this really complex operation, and that includes making sure the child's getting blood flow to their brain the whole time, making sure that their kidneys are happy and they're getting blood flow to their kidneys, but also their hearts are beating. We're giving blood flow to their heart as we're operating on their heart and you've got a nice beating heart the whole time. And it's really changed the paradigm for outcomes with the Norwood operation at our institution. And we have about a third of the mortality that most institutions have nationally because of this change.

But some of the real groundbreaking things that we've done have to do with transplantation. And the first one that was interesting is I was doing work in the laboratory with Dr. Louise Markert. And Dr. Markert is really a giant in the field of immunology. And there are a subset of children that are born without having a truly functioning immune system. And about 25 to 30 years ago, Dr. Markert came up with the idea that what if we took the thymus gland, which is the gland that sits right on top of the heart. And what if we were able to give these children that don't have an immune system a thymus, which can help them to develop an immune system?

So, developed a technique whereby we could do that, and it was the first place in the world to do it, and Duke is still the only place in the Western Hemisphere that does this procedure for kids. And it's changed hundreds of lives of children by giving them immune systems such that they can live a normal life. These children used to succumb to overwhelming infection before they were two years of age. And she's completely changed their lives. And so when I came back to Duke, I started talking to Dr. Markert, and she said, "Wouldn't it be interesting if we started working together here? Because you do heart transplants, and we're putting in immune systems. And what if we put in the same immune system from the same donor that we do a heart transplant with? And would that immune system now recognize that heart as being their own heart and not reject it and not have to be on all these anti-rejection drugs after a heart transplant?"

And so, we did the world's first thymus and heart transplant a couple years ago on a child who is just thriving today with both of these transplants. And so, that's a truly groundbreaking innovation. And if that can be ultimately operationalized so that this could not only help other kids who have maybe a deficiency in an immune system, but also help children that have normal immune systems. And we figure out how to do these thymus and hearts reprogram the immune systems such that they can have transplants that could theoretically last for decades upon decades.

So, that was a really neat innovation in which we were doing work in the laboratory and we saw, "Hey, this is a chance to really push this into clinical care," and we were able to help a child and I'm hoping ultimately we're going to help thousands of children in the same way.

Lightning actually struck twice, because we were in the laboratory and we were working on this idea of children, that children, they're small humans. Their valves need to grow as they grow up. But sometimes we face a situation in which the operation we have to do for that child requires us to replace their valve. And there's no option for a growing valve in children prior to this. And so, you put a valve in, then that valve doesn't grow with the child. Very soon thereafter, you have to replace that valve. And then, you have to replace it again, and these children undergo multiple higher and higher risk operations to replace valves over time.

So, we started doing some work in the laboratory where we said, "Well, what if we took valves and we transplanted them? Kind of like a heart transplant, but just a partial heart transplant." And we transplanted them into the valve position only, not using the heart muscle, just the valves and the arteries that go with the valves. And then, we add a little bit of anti-rejection medication. Will those valves grow? And in the piglets, they did. They grew well.

And then, I was faced with a family that I saw prenatally. And the mom had a child that had something called truncus arteriosus. One of these rare congenital heart diseases that we operate on, in which there's only one artery and valve that comes out of the heart instead of two. And unfortunately, we saw on the echoes prenatally that that valve didn't work. It was a very poorly functioning valve and we knew we were going to have to go down this route of replacing these valves that don't grow. But we've been doing this work in the pigs. So, I approached the family after the child was born and it was confirmed that this valve was not working well. I told them what our idea was about a partial heart transplant. And they said, "Well, have you done this before?" And we said, "In five piglets." And they said, "Well, let's do it. I mean, if this is what you think is the best option to help our child and this could help future children, this is something we want to do, we want to be able to offer."

And so, we did the world's first partial heart transplant in April of '22. And I'm happy to say that that child has two growing valves and arteries. And this is the rewarding thing about watching these kids growing up. I FaceTimed in for his first birthday party. I've seen him walk, I've seen him advance over the last 16 months of his life. And all with the two valves that are growing perfectly and the child is just really thriving and that would not be the case had this innovation not happened.

What's really exciting about it is we've done an additional eight partial heart transplants since that time. Again, all of the children have growing valves that are working well for them. And it's really been an overwhelming success story and I think something that is just starting to take off, but this is going to affect thousands and thousands of lives in a positive manner.

Host: So, a few reflections on what you've said. . It's not an exaggeration to say that this is a complete game changer. Because as you said, that child might have expected at least one or two more additional surgeries over the course of his life and that may not happen now. And that is a big deal. That is a life-altering change in the way we're going to treat this child's disease. And you and I can appreciate the magnitude of that, because it's our day to day. And hopefully, the audience will be able to see how impactful that could be in the life of a child.

 The other reflection I have is we take these things for granted, but when you talk about treating a child who has both an immune deficiency and a major structural heart defect, we're talking about two diseases, either of which could be fatal in and of itself. And then, you add those things together, and it's like you're beginning to scale Everest. So, the idea that you can do a single procedure or a combined procedure to offer hope in terms of treating both of those potentially life-changing diseases is stupefying. It really makes you pause and think that this is just incredible. And I've said in another episode, some of the things that we do sound more like science fiction than they do like science fact. And to me, that meets the criteria.

Dr Joseph Turek: The partial heart transplant was picked up by Grey's Anatomy. So, it is a little bit science fiction, I guess.

Host: That's right. I don't want to let this part of the conversation go without saying that you've done a whirlwind press tour on the heels of the partial heart transplant. And part of that has been. the inspiration for an episode of a very popular medical drama. So again, amazing, the impact these things are having. And I think it speaks to how important of an innovation it is. You know, when the lay press reports medical news, they don't always get it right. I think this time they did. They picked up on a story that's really impactful and really important. So, that's another, I think, cause for celebration for you and the team and the entire heart center.

 You talked about talking to a family prenatally, and I want to bring this out a little bit because it's come up in other episodes. But you know, a lot of the work that you do, a lot of the work that I do is dealing with families who have the expectation of a child is going to be born with a major heart defect. Talk a little bit about that interaction you have with the mother, with the family before the baby is born and the role of that interaction in terms of the child's surgical care.

Dr Joseph Turek: I think that the idea of the fetal ultrasound has been an incredible advance in what we do, and the skill of pediatric cardiologists like yourself, to be able to look at these echoes, which are they're ultrasounds through a mom's belly into a baby, looking at the heart in particular, is really pretty fascinating to me as someone who is not as skilled as you guys are at being able to read these and to tell what the congenital heart lesion is when you're looking at that in utero.

Now, I think it's a big advance because I think it changes how a family is able to prepare for their child's illness. Imagine if you have a child and you're told after that child is born that your child has a severe congenital heart lesion. That's a lot to swallow right there after you've just had your child and this is new to you and you don't have no way to prepare for the fact that your child is going to be whisked off to an operating room at some point. And that's really a lot on parents. And so, the idea that we can diagnose the vast majority of these lesions in utero and then be able to actually have these conversations, not just the cardiologist, but the surgeon. So, what I do is I'm able to meet with these families once they're diagnosed. And we can talk about what this means from a surgical standpoint. What does it mean from an operation right after your baby's born? And how would that operation look? And what would the recovery time be like? And will my child need other operations down the road? And, you know, maybe we can go through some of those.

The ability to be able to kind of wrap your head around what's going on, it's very helpful. And it always amazes me just how by the time a parent comes to me and we have that meeting, they've done so much research. And they really are experts in what their child has and I'm just talking them through surgical aspects of things. But there's something very comforting, I think, for a parent to understand what's going on and not just have this dropped on them that this is what's going on. And it gives them time to read about it and learn about it and ask appropriate questions when they do meet us. There's a lot to it emotionally as a parent with a child with congenital heart disease.

Host: Absolutely. You know, I couldn't agree more. And I would add that it impacts the outcomes. We know from our work in the last couple of decades, as you mentioned, prenatal diagnosis advancing. I happened to train at the beginning of sort of the start of that advancement. So, I've seen the evolution over the last 20 years or so. And you're right. It's arming patients with information. It's helping us make preparation for the birth of these children. I think the audience may not realize or appreciate that there was a time not that long ago that most of these kids, they were surprises both to their families and to the medical community. They would be born in a hospital and they would get sick within the first few hours of life sometime and then need to be whisked off and then treated. And it was an incredibly harrowing experience for families and many of these kids got sick to the point where it actually impacted their eventual outcome.

Today, we've changed that in a dramatic way. We can make preparations. We can get ready for these babies to be born. And as you and I both know, sometimes we get an insight into details that have a direct impact on how we're going to care for that child after the child is born.

Talk a little bit about where you think the work is headed. You have been at the vanguard of so much change and creation and innovation and development of new technology within the field. We've talked about some great examples today. What do you see in the next several years as you continue to innovate and you continue to inspire others around innovation in pediatric heart surgery?

Dr Joseph Turek: I think if you look back at the way that innovation has occurred in congenital heart surgery, there are these moments where you do something that changes how we treat children with heart disease, and those moments happen, and there have been moments that haven't progressed along, right? We've done a few of those and it's, "Yeah, it's just not something that is going to be as groundbreaking down the road as you'd like it to be." When you look at these two innovations in particular that we've spoken of, the co-transplantation of thymus and heart and the partial heart transplant, I truly believe that these are two of the most groundbreaking innovations in pediatric heart surgery in the last 40 years.

And I think that the next step here isn't just we've done two thymus heart transplants and we've done eight or nine partial heart transplants. I think the goal now is to figure out how can we scale this so that this can become available, not only across our country, but across the world to help more and more children. And that's, really where I think things need to go now. These are two innovations that really would change the paradigm for how we treat children if we can scale them. And so I'm putting a lot of my efforts now into figuring out how to do this. So, we've applied for An NIH grant to do a multi-institutional trial for the partial heart work hoping with that kind of investigation and showing that these outcomes truly are beneficial to the patients, that we'll be able make this a much more common thing

Host: So you'd say that an important part And we do is not only innovating, not only trialing things, but also taking those learnings and sharing them with colleagues.

Dr Joseph Turek: Yeah, I completely agree. You can't do it all yourself. And so if you can introduce the idea, make it easier for other folks to be able to do these, that's really how you make a big impact.

Host: I said at the top of the show, and I just want to reiterate that the way this field has changed in the last several decades has been absolutely seismic. Again, the idea that we can take diseases, and we can apply surgical techniques and actually allow children to live who otherwise would not have had a chance is just fundamentally so important in our field. I think it really speaks to the dedication of the people, in our field, both here at Duke across the country and across the world, constantly wanting to push the envelope, constantly wanting to try new things and not settling for the idea that something can't be done, but rather designing new approaches, designing workarounds. And as ultimately, as you've done here with these examples, really breaking through and changing the field in these fundamental ways. Very exciting.

 Joe, I always like to take my guests out by putting them on the spot a little bit, so apologies in advance. And the question is, if you were not a pediatric heart surgeon, who would you be? What would you want to do?

Dr Joseph Turek: Well, from my career standpoint right now, the two things that get me up in the morning are taking the best possible care I can of babies and figuring out how I can advance the field. And if you're telling me I can't take care of babies anymore in surgery, what I would be is an inventor. I would figure out ways to help mankind by developing inventions and things that help to innovate other fields in the world. I mean, I truly love this whole idea of taking a problem, figuring out a better solution for it and especially figuring out a better solution that helps kids down the road.

Host: That answer makes all the sense in the world. I could see you as a great inventor if you didn't have an MD after your name. You'd still be doing things, innovating, creating, designing. That makes complete sense. Joe, it's been a pleasure having you as a guest on the show. I hope you'll come back and talk to us again about the things you're doing, about the direction the heart center is taking, about the care of these children. Absolutely enjoyed the conversation. I look forward to having you back as a guest on the podcast in the near future.

Dr Joseph Turek: I would love to come back. I really enjoyed my time. And I have to say that we have such a wonderful team with our Duke Pediatric and Congenital Heart Center, and it's because of colleagues like you, Angelo, who are just really world class colleagues. And, like you said earlier in the broadcast, these are things we do together. We do all of this together. I mean, it takes a team, and it takes really good team interactions in order to have the success that we've had. None of this exists in a vacuum, for sure.

Host: I think that's a really nice way to bring it all together. I completely agree. It takes a team. It takes a lot of individual effort, but it takes a lot of joint effort, collaboration, thinking through problems together. And, for my money, that's one of the great things about being at a place like Duke because it just creates that environment that's just perfect for collaboration, perfect for bringing people together to solve problems. I absolutely agree and have stayed connected for so many years to our heart center because I continue to feel that same inspiration that you do. Again, thank you, Joe. We enjoyed having you as a guest on the show. We look forward to having you back.

Dr Joseph Turek: Thank you.

Host: Pediatric Voices is brought to you by Duke Children's Hospital and the Department of Pediatrics at the Duke University Medical Center here in sunny Durham, North Carolina. This show was created by Dr. Richard Chung and by me, Dr. Angelo Milazzo. Courtney Sparrow keeps us on track and organizes our work. Special thanks to Debbie Taylor, to Dr. Ann Reed, and to the amazing people at Doctor Podcasting. You can find the podcast and please hit the subscribe button wherever you find your favorite shows. You can also connect with us online at our brand new website, pediatrics.duke.edu/podcasts. Please reach out to us on all the usual social media channels and also at our main website, dukechildrens.org. We'd love to hear from you, so leave us a review at Apple Podcasts or your favorite podcast app. Thanks for being a part of the show. We'll see you next time.