Outstanding summary, Dr. Curran, of a wide range of topics that are in the future, and some of it is now. I think I want to focus first on the concept of angiographic FFR quantum. What do you think? You now have outcomes-based data for GFR. You have automated pullback, because you don't need to pullback. You get the entire vessel of all three vessels all at once. So is wire-based FFR doomed? Well, thank you. It's complicated. I think there's never going to be a one-size-fits-all. But I think as an initial screen, you're probably going to see an uptake in angiographic FFR. You're going to see more systems. Right now, you have to get a separate system that comes with it. It's got to be built into whatever CAD lab system you've got. This comes with your system. It's in there. And I think that's really what's going to drive the adoption of this system. Wire-based technologies are going to be there for cases where you say, OK, the patient had a CT or maybe a CT FFR. And then it comes to the CAD lab, and you're wondering, hmm, this doesn't look as bad as the CT said. Maybe I should run an FFR wire down there. Or even with the angiographic FFR, this lesion maybe doesn't look that bad as it says. Maybe I should recheck with the wire. Oh, this looks worse than I thought. And so it's going to exist for checking yourself or checking the quality of your data. So I don't think we can throw away our pressure wires just yet. Great. Yeah, there's always more progress still in the pressure wire world. Alyssa, do you feel confident enough in the angiographic FFR that you could replace your wired right now? So we have looked at QFR and its correlation to visual assessment by the angiographer. And one thing that is reassuring to me is that in that borderline range of 70%, it just is about the same. And if it's less than 50%, it's awesome. And if it's a tight lesion, it's awesome. So it works the same way. Great. Evan, I know you guys are doing, what, OCT-based FFR in every case, right? You're probably innovating that in St. Francis. What do you think the future is for wired-based FFR? I think wired-based physiology is definitely here to stay. But I think angio-based FFR has a big role as well. Particularly in the US, 10% of the PCIs are performed by non-interventional diagnostic operators. And I think it gives a huge opportunity in cases where you can avoid a wire, avoid heparinizing a patient, where you can figure out if you need further interrogation at that vessel. So I think it's utilizing all the tools we have. Yeah, I think this is really an opportunity where the diagnostic physicians really don't need the wire anymore. And they can just infer as the patients that are even borderline on the angiographic. So that seems like a great opportunity. Dr. Curran, you take a great overview of all this. I noticed that the reimbursement model is really something that obviously limits us in many areas. But CT-FFR has it. Angiographic FFR doesn't quite have separate reimbursement. And you actually maybe save a little. You actually earn a little more money by doing the wired-based FFR. How do you think that the industry should resolve that dilemma? I don't think the industry should resolve that dilemma. I think the physician should do the right thing, regardless of what the cost is, because they're not paying for it. The patient has the benefit of the application of the technology. Now, the model has caused the adoption of technique. But FFR uptake is pretty low still after two decades, because there is no reimbursement. IBIS uptake in Japan is 90% activity because of reimbursement. And it's only 10% uptake in the United States because of no reimbursement. So I think the argument is moot, whether it should be done. It should be done, because it's better for the patient. And however you guys decide to do that, it's good for me. I just want to say one more thing. I think that we shouldn't underestimate it. There are interventionalists who don't use the tools we're talking about today, physiology or imaging. There's not so much imaging talk about today. But the application of an angiographic-based physiology measurement, whether it's 100% accurate or 80% accurate, is going to give them something they don't have. And hopefully, they'll apply that information for better care. Now, maybe they won't even use that. It takes a whole two more minutes. And I don't have two more minutes. That's what they're telling the patient. But anyway, I think it's a great opportunity for future advancement. Great. Yeah, I think this is actually a plug for Sky and our professional organizations, because we can help lobby for appropriate reimbursement. We want to take care of patients in an optimal fashion. And the reimbursement models are the ones that are holding us back. And so it's often banging our heads against the wall. But if we can drive reimbursement towards quality measures and quality care, then we can do better for our patients in a bigger fashion.

angiographic FFR quantum

medical imaging

screening tool

wire-based FFR

reimbursement models