So, Eric gave me the task of Guidelines, Trials, and More, Updates in Coronary Intervascular Imaging and How to Increase US Adoption. So, you know, there's a lot of misconceptions and barriers to, I think, what happens, why we don't use imaging as much in the United States as we probably ought to, which I think is an important key of why we're having this session. You know, ANGIO is good enough, what's the sense of data, lack of training, I'm busy, takes too long, need to get them a kid's soccer game, and procedure costs. So I'm going to go through all these in a little bit of detail. So thinking about the ANGIOgram is good enough, I really bring it back to can we do better, especially in light of the fact that one in eight patients that get stents are back with a stent-related event at five years, and if you have severe calcium, it's actually one in six. And so thinking that we're doing a good job, I think, is, you know, a little bit of a rosy picture when you get long-term outcomes for patients that are undergoing PCI, and it raises discussion of is there an opportunity to chip away at the residual risk for these patients. This is Alan Jeremiah's study. It's an IFR study, but it's really helpful because for me, it frames either the adequacy or in my mind, inadequacy of the ANGIOgram for guiding PCI. They just asked a simple question. If you ANGIOguided PCI and drop an IFR wire in the back end of it in a blinded way, how did you do? And when you use the ANGIOgram to guide the procedure, we leave about 25% of our patients ischemic still with abnormal IFR values. My chip fellow made that slide on the right for me just to prove the point that if you look at the data in the paper, 38% of patients had their main pressure drop in the stent that was just placed. So we're missing lesions outside the stent, and the stent's probably not optimized. This is not an imaging study. We were in large part helping to lead something called the Light Lab Initiative, and Eric and his team were a big part of this, too. This is an image-based workflow study, which just looked at the impact of OCT, but I have this here really to speak about imaging as a class effect because I believe firmly that regardless of which device you use, you're doing better for patients. And simply, you know, we ask simple questions like if you use imaging to guide your PCI, what does it do in terms of decision making? Well, it's really hard to size arteries well for stent implantation. If you look at the 45 operators in Light Lab, if you used OCT to guide the case, you actually change your stent sizing upwards of 35% of the time. And so the nice part about it is we have a tool now which allows us to make really clear decisions based on data that's higher fidelity compared to using an angiogram. If you look across the various phases of an interventional procedure with pre-PCI planning and post-PCI stent optimization, we showed in Light Lab that the intravascular imaging has an important change in terms of what we do with decision making in 88% of cases for stuff that really matters. What's the morphology? How are we going to prep the vessel? What stent length and diameter are we going to do? And then dealing with under-expansion. These are all changes that were made after getting the imaging data compared to what operators would have done if they just used the angiogram alone. So if we use the devices, we end up making very different decisions for patients. We also know that small and undersized stents are the major predictors of MACE. This isn't new information. But when we think about how to do image guide at PCI, it really is the holy grail for making stents well-sized to be already good expansion to get better outcomes. And when we look at IVUS data, we see that IVUS makes our stents bigger with an average increase of 1.6 mm2 in meta-analyses. And if you think the fact that freedom for MACE for minimal stent area is 5.5 mm, 1.6 is a huge number relative to that. It's like 30 or 40% bigger if we're using imaging to guide our stent implantation. Thinking about the proof that intravascular imaging impacts outcomes, I'm going to go through this quickly because it's not meant to highlight any one trial. It's meant to overwhelm you with a huge amount of data which clearly proves that intravascular imaging improves outcomes in PCI patients. Two randomized trials done on separate continents two years apart give you numerically the exact same reduction in MACE. IVUS reduces stent failure by half. Presented at ACC four months ago, a third randomized trial using both IVUS and OCT, IVUS and OCT reduced stent failure by almost half in complex patients. Odds ratio and meta-analysis of the outcome we really care about cardiovascular death, 0.6 for using imaging to guide PCI. Overwhelming number of registries in upwards of 75,000 patients showing mortality benefit of angio-guided PCI being worse, IVUS and OCT help to save lives when patients get stented. Slide I board from Gary Minch, not meant to be read, to show you the overwhelming number of studies which demonstrate the value of image-guided PCI. So we talk a lot about Zions versus Synergy versus whatever stent you may like, TLR rates, stent failure. If I could sell you a stent that cuts stent failure in half, would you buy it? Of course you would. Just use an imaging catheter. So based on the data I showed, everyone in the United States is getting an image-guided PCI, right? There's a great study using a different database which showed it's about 6% in the United States. If you look at Japan, they're imaging 95% of PCIs. We could talk about why that is. The U.S. guidelines, I would argue, unfortunately, have intravascular imaging for coronary PCI at level 2A evidence. I think this is a missed opportunity. It should be revived now based on RenovAIT and several other studies which are going to come out. I think they're going to further support this. I put this to Twitter. Should it be a classroom recommendation? Little bit of answer bias, but 86% of the people agreed with me. And so thinking about lack of training in terms of why people aren't using intravascular imaging, this is something we worked really hard on, and colleagues and I built something called MLB Max to make imaging easier. It's the main way that we actually try to teach IVAS or OCT-guided PCI because this is data from the CRF Fellows course colleagues put together, and it showed that our interventional fellows don't feel competent with IVAS or OCT-guided PCI. This is an opportunity for us to do better in terms of our competency and our fellows' competencies as they graduate. So I'm not going to go through MLB Max except to say that there are simple and easy paint-by-number ways to do stenting with image guidance that make it simple, teachable, and consistent. This is what we looked at in Light Lab. We now know what defines an OCT or an IVAS-guided PCI. It's no major dissections and good expansion. It's really easy to learn how to do this, and systems are making it easier. So hey, like we all have busy practices. Learning this might be hard. It's going to take too long. That's not true. If you look at Light Lab with our study or if you look at Disrupt CAD, which both had imaging arms, it adds either no time or at most nine minutes to the case to do two imaging runs to plan the case and then make sure the stent is optimized. In procedure costs, we're all going to use an IVAS catheter to help get better outcomes. When you think about the fact that if you use imaging to guide stenting, you actually use less stents because you're making decisions based on the data from what's inside the artery versus the angiogram alone. And when you think about the fact that about 12% of all US PCIs are for stent failure, ISR rates are marginally increasing, not getting better. This is about 100,000 cases per year. And Bobby Yeh, who works with Eric, has a really nice study showing that TLR for stent failure has one of the highest mortalities for PCI patients. So it's common, it kills people, and it's actually expensive to treat. There's a really nice study from Sunil Rao, which has talked sort of existentially about quality metrics in PCI and physiology to identify lesions that need to be fixed and imaging to optimize our PCI, really high quality markers of what a best case and best practice scenario is currently. So it's actually time to raise expectations. Increasing adoption has been hard. We tried to simplify it with MLD Max. The data, I think, is there. This is the paper which my colleague Brian Bergmark wrote in terms of how our center looked at the data integrated and tried to improve adoption. We trained our techs. We trained our partners. We put these big posters in every lab and had an agreed-upon way to do an image guide to PCI. And we started to track it as a quality metric. When we started this process, we were imaging 20% of the program. Now month over month, I pulled this from our quality conference just two days ago. We run it by 86% to 87%. Quarterly, I get my de-identified use of radial, use of contrast, and use of my PCI for imaging. So we all see that in a nonthreatening way, but we can compare ourselves to our partners. Those are things we've done to try and drive adoption. And so thinking about that, we all seem to get the guidelines changed. As I talked about, I think that's an opportunity for revision, especially as more data comes down the pike. So for summary, what's the evidence for routine intravascular imaging? Neandrogram is a blunt diagnostic tool. It really allows us very poorly to assess PCI success. Physiology studies multiple show that. Image-guided PCI reduces stent failure by 50%, and at least in meta-analyses and registries, it saves lives. I firmly believe intravascular imaging is underutilized in the U.S., and there's a bunch of hashtags, which we all sort of go over Twitter trying to get people to increase adoption and push the envelope. Thanks very much for having me. I appreciate it. Wonderful talk, as always, and I like that one slide with 400 different trials and words because it just shows you where we're at with evidence for this technology. So without further delay, I'm going to have Dr. Kearney from the University of Washington come up and just present the case where intravascular imaging helped her do something different in her procedure.

coronary intervascular imaging

adoption of imaging

misconceptions and barriers

angiograms

MLB Max tool