All right, fantastic. Well, again, thank you all for being here. Thank you to the organizers. Thank you to our moderators and fantastic panel. My name is Robert Riley from Seattle. And I've been asked to talk a little bit about the gaps in the use of intravascular imaging and the impact on patient outcomes. And these are my disclosures. So again, coronary angiography, as has been discussed, has really been the bedrock since time incarnate for the gold standard for diagnosing and guiding the therapy of coronary artery disease. But there's obviously inherent limitations making clinical decisions based off a 2D picture of a known 3D structure. And in order to address that, intravascular imaging was developed decades ago in order to help improve our evaluation and characterization of coronary disease. It helps in terms of diagnostics, so mechanism of ISR, vulnerable plaque, CTO cap identification, these types of things, and treatment, treatment length, vessel diameter, plaque characterization, and how we optimize our stents. And when used properly with data is very clear time and time again that we can significantly improve hard outcomes, as we've discussed. Whether you use IVUS, as seen here, or multiple different studies with OCT, again, these are hard outcomes and not necessarily subjective ones. The question then comes, is one better than the other? And the relatively consensus would say OCT and IVUS, no significant difference regardless of which one is used. As long as they are used, because both of them have significant improvements over angiography alone. Unfortunately, as Dr. Rao said just a few minutes ago, uptake continues to be very low here in the United States, still trying to get to that 20% mark or so. Again, there are other countries in the world that have much higher rates. But again, it continues to be relatively abysmal here. So the real question is, and the meat of this talk is, despite this mountain of data, why is use so low? And we're going to go through a couple of things. And first thing we have to talk about is financial. Particularly post-pandemic, anybody involved in running a group, a practice, an organization understands that there are new challenges. And finances are a big piece of them. And unfortunately, we no longer get to practice medicine in a silo. These things do impact how we take care of patients. And there's a couple of different aspects to the financial piece. First is the cost. And there's both the direct cost, so how much does the thing cost that I'm using, and indirect, the time that we use in order to use the thing. There's also carts, whether there's integration. And that all gets bundled into how you do your contracts. There's also a reimbursement piece, right? How does the hospital and physician get paid for doing the thing that you're talking about? And there is an overlap there where I do think there is the potential for real opportunity. There's a potential from a guideline standpoint where we make these a class one indication, where physicians can go to their leadership and say, this is what my society says I should do to improve patient outcomes. That's very helpful. There's also a potential for bundling, whether it's from a contractual standpoint at a hospital by hospital level, or from a payer standpoint. If you do PCI, we pay for you to do imaging. There's a lot of different ways to approach that and opportunities for growth in that regard. Education is another big piece. It's simply not enough to put an imaging catheter down a coronary. One has to know what they're looking at. And there's been a lot of different types of educational models that have been put out. I would say for OCT, the MLD max has sort of been the baseline, the thing that we all come to know and understand what that means. The MLD being the pre-PCI vessel prep, max being the post-PCI stent optimization. IVUS 1, 2, 3 has come on the heels of that. It's not really quite out in mainstream yet. We're still working on the manuscript. There's a few logistical issues. But same principles hold, 1, 2, 3 for vessel prep, 1, 2, 3 for post. We know that when we use these models, we improve outcomes. We also know from recent data that if you simply stick a catheter down without a model for how to use it, you unfortunately don't move the needle in terms of major adverse events compared to angiography alone. But when we do use these models, that's where we see the real benefit in reduction of major adverse events. So let's say we get the finances worked out and we start to get a better grasp of what we're looking at. We also still need to improve our intravascular imaging catheter. And this warrants some time for discussion. So when I think about a product utilized in the cath lab, I try to come up with some fundamental tenets for how do we utilize a product and how do we utilize it well. And the first is we have to have easy setup, right? This is important for staff acceptance. If your staff doesn't want to do it, it's gonna be very hard for the physician to do it. The next piece is ease of use. This helps us with physician acceptance. And those are two very different things. The next is that the piece of equipment has to provide high fidelity, quantitatively usable information. This is extremely important. The thing has to give you something with which to act on in a very quantitative, reliable way. And then finally, there's gotta be low risk of complications, right? The pros and cons have to be in the patient's benefit in order to utilize the device. And if these four tenets are not met, then we don't have uptake of said device. The market shows us that we don't have uptake of imaging, so clearly some of these are not being met. What else does the market tell us? Well, Philips has been the biggest player in the imaging space for a long time. Time and time again, surveys show us it's because of the ease of use. So that's why we know it reinforces this idea of easy setup and ease of use. We know this is important. Now what about the high fidelity delivery of information? This is where Philips is gonna fall short, for example, because of the lower resolution of the image. This is where some people will move to an HD IVAS system because it's more readily reliable, higher fidelity, reproducible information. But we still don't have the delivery of actionable items at our fingertips. Now, Avigo Plus will help with that from an IVAS standpoint. Ultreon, initially not great, getting better. Again, the deliverable information of which we can take action. The other piece is not delivering too much information. Lumion 4 taught us that there's a lot of things we don't need to pay attention to. We need to make sure we deliver actionable information at our fingertips. So what does it look like to have an optimal IVI device? Easy setup, as we talked about. Plug and play integrated into workflow. Mobile cards are not ideal. That's working with vendors across companies to get that done. Ease of use, as we talked about. I think that OCT will continue to not have market permeation because of the need for blood clearing that's asking for poor fidelity. We need rapid pullback, correlation of information and co-registration so that we know where to take these actionable steps. And we need easy interaction with the system. Most people will not use that interaction, but as people use more, they will wanna play around and sort of look at different aspects. So we wanna make sure that that's available as people become higher end users. And then again, back to this high fidelity quantifiable information. For pre-PCI, we know what the things are that matter. We need that delivered right there on the screen. And then post-PCI, again, those metrics that we know affect outcomes delivered. And this is essentially what it would look like. You'd get a summary screen pre-PCI. Tells you diameter, length, side branch and jeopardy and need for modification. And then you'd get a post one right after it's done. It comes up and simply says, what is your MSA? What do the edges look like in terms of burden or dissection? That is the rapidly available, quantifiable, actionable information that we need and that we can actually change outcomes with. So in conclusion, what are the steps that we need to improve IVI use? First, we need to upgrade the guidelines. This will help from getting it into the cath labs and getting people the understanding they need to use it. We need to work towards removing financial disincentives of use. This is a cost and reimbursement standpoint. We need to improve our educational offerings. Sky is proud to be doing hands-on. You know, Evan Schlossman here has been a real leader in that in terms of getting our hands on things. That's the way we can really educate with imaging. Improving our image qualities we talked about. We want E. coli ease of use with HD IVUS OCT image quality. We've got to remove the need for blood clearance for OCT for it to gain a foothold. This is where hybrid OCT IVUS systems can potentially make some improvements there for us. And then we need to improve our algorithmic information delivery. Again, as we talked about, we need the information we need right there in a summary screen, both before and after. And that's where AI could potentially really help us. If we're able to get aggregated, de-identified data to help this machine learn and then deep learn to be able to have better discrimination than we certainly ever could. And then as we move towards CTAs, replacing diagnostic coronary angiography, which is likely the future of our field, we really need the ability to overlay and correlate this with our intravascular imaging. Thank you all very much. Thank you.

intravascular imaging

coronary artery disease management

patient outcomes

diagnostics

treatment optimization