I'm going to try hopefully to wake you up more after breakfast, get you ready for the session. I love imaging. It's my passion. Physiology is my passion. I don't like shock. I'm teasing. I do don't like shock, but I thrive to find a solution to this high mortality morbid condition. I'm going to go over a case because I want to make this interactive. I'm going to ask the panelists to chime in. The way I treated the patient is not necessarily the way you should treat the patient. There are multiple ways to treat a patient coming in with complex coronary heart disease, but at least I'll show you what I did. If you disagree, if you have better data than I do, I will learn from you, and then I'll adjust for the next patient. So these are my disclosures, and for the non-imagers or the non-image believers, I always heard this. There's no data. That's debunked because there's a lot of data, and I don't want to go over data. There's a lot of data for many years that imaging, intravascular imaging, changes mortality, makes a better outcome for our patients, but we still didn't do it because the argument was wherever I go, people tell me, you know what? There is no guidelines. So I'm putting the slides here because I have to show some slides. My goal is to show you the case. And then people says no guidelines. Well, guess what? That's debunked too because the Europeans are a bit ahead of us, probably six months ahead. I hope. And that's what they said. They moved imaging into 1A and specifically in complex coronary artery disease. They're not advocating to do this on every type A lesion you see, but at least they're telling you if you're dealing with complex lesions, particularly left main, true bifurcations, and lung lesion, you need to do imaging. IVs or OCT, it doesn't matter. They're agnostic, but it's a class 1A in Europe. So I tell my patients, if someone put a centennial without imaging and you have this lesion subset, travel to Europe. Maybe more expensive, but you can still do it. Here we go. Anyone can participate. 84, hypertension, hyperlipidemia, regular patient, UC, CKD, went to an outsized hospital with some palpitations, chest pain. The typical story. She has shortness of breath for the last couple of weeks, got worse. She went to the emergency room. EKG, if you're still looking at an EKG. I still do look at an EKG, especially when I'm driving in for a STEMI, because everyone sees the tombstones. Nobody sees the complete heart block that's underlying it. Everyone sees the anterior wall STEMI, but no one sees the compensation and tachycardia. So I'm going in with a large tombstones, LED, STEMI. I'm thinking transfemoral, a mechanical circulatory support in the room, S1. That's what I tell my team when I'm going in. So I still look at EKGs, not to make a diagnosis of a STEMI because an echo is faster now in 2024, but EKG is important. Her EKG is irrelevant. She gets the diagnosis with an STEMI. I tell my fellows if the troponin, high sensitivity troponin, is more than your paycheck, that's a real STEMI. That's a real insult. So that's it. 9,000. It's a true story. And she was a bit on the hypotensive side and tachycardic, as you saw in the EKG. This is her angiogram. The reason I'm showing the angiogram, it's going to play for about 27 seconds. We have three pictures of a semi-normal RCA. I urge, if there are fellows here, stop taking pictures of a right coronary artery if it's not the presenting problem. It's a single artery. Take LAO cranial, use a little of contrast, and move on. I told you in the history the patient has CKD stage 3. She's coming to you hypotensive. ATN is knocking on the door. Acute kidney failure is coming your way no matter what. So less images. And then we take more images where we are in the cusp. I'll show you in a second. This is here. They're not trying to do TAVR, believe me. This is a coronary angiogram. So we took three pictures of the cusp. If the catheter is not moving, move on to a different catheter instead of giving poison called contrast. And boom, here we go. We found the problem, finally. Last picture. Yeah? Questions? Okay, now what? CABG or PCI? Show of hands. I have to move quickly. Yeah? Okay. Okay, good. Here we go. So need more data to decide? Yeah, more data. Okay, so patient gave you the data. She said, you know what? I'm 84. I ain't doing no CABG. You either fix me or send me home. Okay? And obviously I'm a PCI guy. No one goes to CABG. They need to starve. Okay? They don't get Impala 5.5. So patient transferred to us for complex left main. EF is down. She has moderate aortic stenosis. We call it moderate, but maybe if we give her a normal ejection fraction, she will get a better gradient and she will get a TAVR with Lord Sattler. But here we go. This is it. Strategy. What do you want to do? MCS? Yes. NES with what? Who wants to do MCS? Panelists, can I ask you? Okay. Okay. MCS with what? Impala, ECMO, Impala maybe. Okay. Yeah, I like. I need the right hard cap to make a call. Yeah. Right hard cap. West wing, East wing, Democrats, Republicans, elections, DC. No? Optimize. Okay. We need the right hard cap maybe. Okay. One stent or two stents? I'm thinking because now I see this culture that if you know, if you're planning to go in and out, maybe you don't need to put a 14 French Impala. Maybe you do something else. Maybe you just leave off it. If you're planning to do DK crush, 16 steps, a lot of manipulations, then maybe you should do something. I hear all these in the back of my head. Who wants to do one stent? I don't know. I mean either. I don't know. I need more views to make the call. Yeah, maybe more views to make the call. How about I do imaging and would that make a difference in my life? Well, I don't know. The fellow said, up to you. You're the boss. I did the right hard cap. Yeah. Did the right hard cap and this is it. I don't know how to interpret. I call heart failure specialist. Or Mohit. I usually call Mohit. Say, Mohit, what do you think? What should I do? He said, doesn't look good. You agree? I sound like a politician now. Give you no information. Just babble. Here we go. Index is low. Wedge is a bit elevated. And so, couldn't put an impeller. It's a very small, tiny woman with a very small vasculature. I truly felt it's gonna be high risk. I ended up putting a balloon pump. You agree, you disagree, we'll debate that. Hopefully the next, the last 24 hours and the next 24 hours or 12 hours will give us more answers. So I love this one. I did a balloon pump because that's the only thing I could do. And that's the other view that the panelists asked for. I took this view. I felt a spider, an allele coral will give me a sense of what I'm dealing with. And this is it. Okay, who changed their mind? Who wants to do one stent or two stents? This is it. Two stents. Two? Going once, going twice, two. Yeah, I agree. I said I'm gonna go two because I think there is involvement of both limbs of the bifurcation. This is back in the days as a Medina 111. I say back in the days because I truly believe classifying a bifurcation based on an angiographic view should start phasing away because the guideline says 1A if you have a bifurcation to use imaging. To define true involvement of both limbs of bifurcation, I believe you need to do imaging on both of them to understand what are you dealing with. Now, who wants to do arthrectomy specialty balloon like a cutting balloon, scoring balloon? Who wants to do lithotripsy? Who wants to do NC? Who wants to do all of them? With confidence. I want someone to stand up and say, you know what? I'm gonna do rota-circ, rota-LAD, and I will do cutting balloon because rota-cut there is data, and I will put this. Anyone confident? You need imaging. Exactly. So the only thing you're confident with, you needed the right heart count, which I agree. You needed MCS, which we all agreed upon, and then now we agreed two stents, but we have not agreed on the treatment strategy because we need imaging. I need more data to decide. So like every other day, I wired both lesions. I sound like a very complex guy, every other day. Okay, like every once a month, I do this procedure. Here we go. I ballooned both. I did a predilated kiss. I don't know, I learned this in fellowship that if you manipulate this arm, you manipulate that arm, you need to kiss them before you leave. At least by the time you prep your ivis or do something, your carina is stable. I don't know, I believe in myths. That's what I did. And I went in with ivis. This is the LED. See something, say something. You're in Washington, D.C. and New York. Yeah, there's a lot of calcium. There's the calcium. Everyone can see the calcium. Tight areas. Calcium is on one side of the town, on the other side of the town. There's 360 calcium here, but it appears to be a bit more fractured than it's all constrictive. And then we're back to the left main with some intimal thickening. I'll explain it in a still frame. Here we go. So this is the tightest area in the LED. It's a 2.7. Anything below four, we publish the data out of the hospital center. And an osteoLED or proxLED with an area of four or below correlates very well with an FFR of 0.75. So this is certainly a tight LED, which we don't need to prove that. We don't need to do physiology for this. But here we go. This is your side of town where there is calcium from probably 12 to five. The calcium is deep. How do I know it's deep? Because there is fibrotic tissue. Whenever the tissue looks like adventitia, that's fibrotic. Whenever it looks like media, which is this rubber band, that's lipidic. If it's bright with a dropout signal, that's calcium. So that's how I remember things. Here we go. This tissue from the lumen to the calcium looks like adventitia. So it's a fibrotic cap on top of a thick calcified plate. How do I know it's thick? It is thick because it's a pitch black dropout signal. If there are reverberation, that signifies thin calcium. This is a thick, big gumbaya sitting on the osteo of the LED, and it's a bit deeper. That becomes very handy in a second. I don't, I meant to tell you the characteristic of calcium. I'm running out of time. Yes, okay, done. Here we go. It doesn't work. Very tight. It's fragmented. There's a lot of calcium. I talk a lot. I'm sorry. Now, based on this scoring system, I have a lot of calcium, 180 deep. I need to do some modification before I put my stent in. I follow skies whenever they publish something, and this is what they publish on how to treat calcium. I did imaging. Did the imaging criteria met? Yes. What do I need to do? That's my decision to do. With an arthrectomy. IVL of a specialty balloon. If I couldn't get my IVs through, then I will have to divert into this part of the diagram, but I decided to follow this route, and then now I'm going to put, I do imaging, I treat, and then I will stent, and I'll proceed with PCI, and that's what I did. I decided to go with a Wolverine. The reason is I didn't have 360 calcium. I have calcium covered by fibrous tissue. Arthrectomy doesn't ablate if it hits flesh. It ablates if it hits calcium. Deep calcium needs to be treated by either a specialty balloon, such as a cutting balloon, or NC balloon, or intravascular lithotripsy. I don't like inflating intravascular lithotripsy for 10 seconds in the left main, and I think that's the essence for why we're doing disrupt cat duo, which is the new shock wave we're testing now in a trial. So I did IVs on both. I did CULOT, because I didn't want to do DK crush. You might disagree with that. CULOT is less steps. It's easier for me to remember, and I'm not going to manipulate a lady with an index of one, three, and balloon pump. This is the criteria that I go by. If you're Caucasian in the Westernized world, you need a 10, seven, and six. Akiko Mahara, my teacher, I learn from her all the time. This is for Caucasian. This is for Asian. I use this data in this lady, because she is a bit smaller, and she's an elderly woman. I didn't want to push my limits. I got an LED stent, and I get an MSA CERC stent, both expanded. This is the distal. This is my stent, and these are the final pictures. I'm going to open to questions in a second. Here we go. And in conclusion, I think IVs unite us. Now, there's no one of us would disagree that what you saw in IVs made your case simpler, made your strategy more defined, and you did not hedge. You saw calcium. You treated it the way you should. You know it's a bifurcation, and with that, I say thank you. I'm sorry I took more than my time. Thank you very much. Thank you.

coronary heart disease

intravascular imaging

treatment strategies

coronary artery disease

imaging data