Thanks very much, Professor Morisato. That was really a very, very informative talk and really outstanding use of OCT in one of the more complex aspects of bifurcation stenting. I think in the interest of time, maybe we'll move on to the second talk, which is bifurcation case presentation with OCT Imaging and Optimization with Richard Schlofmitz. All right. So I'm going to be talking about optimizing bifurcation treatment, and I'm going to show it with BOOM!, with the Ultron 2.0 software. And this is the new AVID software from what we've been using for several years. The BOOM! technique is also MiniCrush or NanoCrush, different names. I call it bifurcation OCT management. So basically, this was a 65-year-old male coming in with shortness of breath with a positive stress test with anterolateral ischemia. And on the angiogram, you could see that he has an LED lesion with a diagonal bifurcation. And any time I have any kind of bifurcation, LED diagonal, left main, or circ, I always go to a 7-front sheath because I'm prepared to image both branches. And with the technique that we use for imaging for OCT, we always like to prepare beforehand using the MLD Max algorithm. So here you see the baseline LED OCT. And what's going to be different about Ultron 2.0, the first confusing thing, which you get used to pretty quickly, is proximal and distal is different. Distal is to your right, and proximal is to your left. So that throws you off a little. But you have your angiographic co-registration on the left. And the co-registration here is a marked improvement before. You have your cross-sectional image on the top right. And then you have your 3D luminal image down there, which gives you the length of stent you're going to use so you can get into normal tissue. It gives you the luminal area. It gives you EEL detection. So if you could detect the EEL, you see those dotted lines on the three-dimensional screen? That's an area where the computer can analyze EELs. So it gives you automated calculated EEL. So if you look on the three-dimensional screen over here, you see 2.82 distally is my EEL. Approximately couldn't tell you, so you have to measure it. But you have a luminal area of 254. It's 23 millimeters length. And I can actually measure, so I can pot very accurately, how many millimeters after a bifurcation I need to go to get to normal tissue. So instead of a 23, if I needed a 28 because I wasn't landing in normal tissue, I can optimize my landing zone of pot. So you're just not putting an eight in. You're putting in length of a stent to get the best tissue. It's given me a wealth of information. So you'll see I have morphology. I have length. I have size. I have lumen. So let's look at this baseline LED morphology, and all this is artificial intelligence. So in my cross-sectional area, you see there's an orange line there. That depicts calcium. And if you click on the screen to the right, you can blow it up and see the total angle of calcium and the thickness of calcium, which is tremendous information. And you can set this to any display threshold you want. If 180 degrees is what you want to see, then anything 180 degrees or more will light up on your screen as orange, and you'll see in co-registration, it'll line up on the actual vessel on your angiogram. So you know exactly the depth and length of calcium, which is critical in assessing if you need to do pretreatment with some type of atherectomy device. And here I see I have mixed morphology. Here is calcium. The arc maximum is 73 with a thickness of 0.73. Let's redetermine what I'm going to do. Now in terms of length, I can set my distal and proximal markers, and I'm all about landing zones. I want to land in a good landing zone on both sides, proximal and distal, so I know I'm not going to have a dissection. And the dotted lines on the bottom or on the cross-section, you see those dashes, represent where the computer is analyzing EEL. And if it analyzes EEL, I see distally I'm 2.82, and that'll tell me that I'm going to go with, let's say, a 2.75 stent. My length is 223 millimeters, and I have 8 millimeters where I can pot to get to a bigger-sized vessel. So that was length. Now I want to get diameter, and as I pointed out, before distally I have EEL calculated by the computer, but proximally I had to measure it, and when I measure it, I can measure it at 3.87. So artificial intelligence helps me along with measurement of calcium and measurement of the size of the vessel, the diameter. So my baseline LAD-OCT information, it told me about calcium, it told me my length, and it told me my diameter. So once I do the LAD, I now go to my diagonal, and in the diagonal I see that I have pretty significant disease at the bifurcation where my—you can see at the bottom of the screen, it says MLA. I have my MLA listed there. So I know my MLA, and eventually I'll know my MSA as well, and everything's depicted for you. So I know I need a 12-millimeter stent. My EEL distally is 2.34, and I'll calculate it proximally. So now we go to morphology. It's fibrocalcific. It has a 70-degree arc, 2.73 millimeters in thickness. My length is 12 millimeters, and I come up with my distal reference, 2.34. So now I have all the information I have in my baseline LAD in diagonal, so I can go ahead and strategize how I'm going to do this procedure. And here is a summary of my diagonal information. And please keep this in mind, for both the LAD and diagonal, this takes me less than a minute to do each one, less than a minute to get all this information. I have my MLA. I have my areas and my diameters. So first I do a noncompliant balloon in the diagonal, a noncompliant balloon in the LAD. I then follow with a drug-eluting stent in the diagonal. I then use a noncompliant balloon in the LAD to crush that stent, and I go, you know, I don't use DK Crush, but I think that any technique you use, and there are many different techniques we use, whether it's Coulat, DK Crush, or this mini-crush or boom technique, as long as you document it with imaging, I think you're doing the right thing. So I then follow with kissing balloons in the LAD in diagonal to open up my struts. And then I follow with a 27523 in the LAD. I pop with a 3-5 balloon in the LAD, and all this was calculated beforehand, knowing I need it. I then recross, and I use noncompliant balloons in both vessels. I dilate and I kiss. And now I have my final OCT in the LAD. And what I'm going to be looking for in the final OCT of the LAD is do I have distal dissection, proximal dissection, and because my landing zones are good, I should not have that. And what's beautiful about this technology is that it tells you if you have stent expansion or not, and if your stent is not expanded, and again, you can set this to 90%, 80%, it'll show up on your coregistration over here where it's white, it would show yellow. So you know exactly where you have to dilate afterwards if you're underexpanded, and it also shows you malapposition. So both on your coregistration and your three-dimensional, you can see where you are. So that's my final OCT of the LAD. And now I look at my diagonal, and I'm going to see the bifurcation there, and I have no dissection. So I know I have expansion in both the LAD and diagonal, I have apposition, I don't have dissection, and this is my final LAD run, and you can see no dissection distally. My areas, my percent expansion, you can scroll, you see it all across the board where your expansion is. But here I'm 99, you can see at the bottom, it shows 99 expansion, MSA of 4.46, all the data set you have. And here's my bifurcation, here's the LAD, and there's the diagonal. And you see the two perfect circles, which I like. So my baseline LAD, I have no dissection. My proximal distal reference, I have 100 percent expansion of both sites. I have excellent apposition. The orange where it shows it's malapposition is just a bifurcation, so it's not really malapposition. And this summarizes it right here. You see 100 percent expanded with MSA of 4.4A. That's my LAD. And here you see the apposition, my bifurcation, and my expansion 100 percent. And the final LAD assessment is no dissection, excellent apposition, excellent expansion. And this is the three-dimensional picture of it. Now I'm going to look at my diagonal and do the same thing. So I'm going to check to see that if I have dissection, do I have expansion, and apposition. And you can see in a matter of moments, you can see exactly where you stand with your diagonal bifurcation. I have excellent luminal area at the bifurcation point where the restenosis rate is the highest. And my MSA is 3.13. There is no medial dissection, as you can see in the cross-sectional. And I have excellent apposition. You see those two beautiful circles at the bifurcation. And I have 92 percent expansion. So in summary, no dissection, apposition, with excellent expansion. Now the beauty of this also is this OCT software shows me what I started with and what I finished with. On the top, you can see that I start with an MLA of 2.12. And when I finish, I have an MLA of 4.57 with 100 percent expansion. I can play them side by side. And now I do the same for my diagonal. I had an MSA of 0.92 up to 3.12. Very elegant to compare these two. This is all new software technology. So in conclusion, there are many techniques you can use for bifurcation treatment. The only thing that's critical to me is imaging, whether you use IBIS or OCT, whatever you're comfortable with. I don't think you can do bifurcation successfully without imaging. And you can't just put a catheter down. You need to have a pretreatment strategy. You need a stepwise approach using MLDmax with co-registration to guarantee that you're going to get the best result. And if you look at that cross-section on the left, that's what I like to see when I have a bifurcation. Thank you. Terrific, Rich. We have a couple of minutes maybe for a little bit of discussion or maybe questions. And while our panelists are gathering their thoughts, maybe I'll ask. How often, I mean, Rich, you're a big OCT user. And as you've demonstrated very elegantly in that talk, you get a tremendous amount of information that allows you to plan your procedure. How often are you having to, you know, post dilate multiple times? Or have you minimized that because you already sort of know exactly what the vessel dimensions are, what the amount of calcification, you know? Tell us a little bit about that. Have you reduced the resource use in your lab? So what's great about it, you know, when people first tell me why they don't use OCT, and there are 50 different reasons why they don't use it. And there's only one reason why people don't use it is because they're lazy. But, you know, one of the reasons is that it takes too much time. But I totally disagree. I take many less angiograms beforehand because I'm looking at three-dimensionally. So I'm using less angio, less floral, number one. Number two, as we pointed out, I know exactly the length of stent, the size of the balloon I need to pot in each vessel. So as I'm doing things, my staff is getting all the equipment. It's right there. And I'm doing everything beforehand. I'm not doing anything in between and going back and looking. So to answer your question, if I know I have greater than 270-degree calcium that has depth, I'm going to shockwave that, right? So I'm not going to be in a situation where I have to go keep going back with balloons and just be satisfied with the result. I'm going to document fracture before I stent. So I know I'm going to have full expansion. So you're absolutely right. OCT lets me, with precision, optimize beforehand so it takes much less time after. Dr. Pinilla, let me ask you a question. I mean, you've been really heavily involved in education internationally around OCT. You know, some of the complaints I've heard, or maybe not complaints, but maybe apprehension around OCT, particularly for people who have used a lot of IVUS, is that they have trouble adjusting their mind's eye to the images at OCT that OCT shows. Can you talk a little bit about how you approach the training for OCT when you're giving lectures or when you're training fellows? Yeah, it's interesting because people that have been using IVUS for a long time feel very confident doing it. So I think I agree with Richard in the point that if you're very confident with one technique and it works for you and you use it in your patients, then you should use that one. If you had any interest to train in another imaging technique is when OCT comes. So we see since OCT has been available, training in OCT with all of these artificial intelligence and tools, so the OCT consoles, as Richard demonstrated in his talk, are pretty, pretty useful when you're doing PCI. So I find that the new generations love this artificial intelligence, a software that tells you where the calcium, where the EL, where the measurements are. And I find it's actually easier to train people in OCT when in your post-PCI, in less than one minute, you're seeing your color code. You see white for a position. You go to both proximal and distal ages and you look at this function number and you're done. So people are, if you train them in OCT, they understand how efficient they could be. And I think the switch will come from that. However, training people in imaging, I will say not everybody has both modalities, imaging modalities in their cut labs. So if they have either, be comfortable with what you have. If you have both, use them appropriately, right? Like sometimes we use IVOS for OCLF main, for vein grafts, for big vessels. So I think being efficient with both is helpful. And if you have both, train in both. I think that will be the message. Great. Tanvir, any comments before we go on to the final lecture? Sorry, you're muted there, Tanvir. Let's ask Professor Morisano what his thoughts are on the OCTs, new software, and what his thoughts are about how he approaches the application. Yeah. I approach the bifurcation intervention using the OCT as a pre-PCI observation for the main vessel and the side branch to identify the vessel size and morphology and the classification distribution. So that resulted in the optimal device selection and over-treatment for the side branch. So we can select the optimal size and the optimal device for the bifurcation intervention. And after PCI and side branch wiring, we assess the side branch wiring recrossing point and optimal pod. After pod and side branch wiring, we assess the side branch wiring and assessing the pod efficacy. Especially as a bifurcation core, polymer expansion is very important for the optimal pod. And then finally, we assess the stent expansion position in the final case of bifurcation. So we at least pull back four or five pullbacks for the bifurcation intervention. Therefore, to reduce the contrast medium, we use dextran. So that is the purpose of using dextran instead of the contrast medium. As a result, the amount of the contrast medium is not different from the IWAS guidance. Yeah. Professor Morisano, do you think the new software that Richard showed, do you think your rewiring strategies might improve with the new software? The new software, I hear about introducing the new software with the 3D contraction system. Now, the present system does not have the 3D system. However, we still have the 3D system. So in the bifurcation PCI, we still use the 3D OCT system. So maybe next year, we will develop a new system with the AI system and the 3D reconstruction system. So we can use both of the systems. So for someone who's just coming out of fellowship and is predominantly trained in IWAS or is mid-career and wants to make a pivot into imaging, what's the most practical way to get trained on these systems? Natalia, maybe you can take that question. Yeah. So I think education is the most important, both barrier and the one that opens your confidence to use these technologies. Honestly, I feel any fellowship program should have experts in imaging modalities that could offer the fellows training in both technologies. Like a fellowship program should have faculty and professors that are very confident in both and open these four windows to the fellows. And I think all companies in general have amazing opportunities for training. Once you do systematic training, I believe the easiest cases you pick to do imaging, the better in the beginning. So don't do training and go for a double standby bifurcation PCI because it will be very overwhelming. So I recommend once you have an idea how these consoles and the tools and the artificial intelligence, use it in easy cases for you to become comfortable with the software. And once you do that, you do 10, 15 cases when that is when you jump into a little bit more complex cases. But I believe the strengths in imaging come from good training from your fellowship program for sure. And using these opportunities of these webinars and all these opportunities for training.

optical coherence tomography

OCT imaging

bifurcation stenting

Ultron 2.0 software

morphology assessment

stent placement