Outstanding summary even, thank you very much. And I thank all the speakers for being on time. We're going to allow ourselves to run over because you guys are still eating and we, you know, there's nothing going on except to please visit the exhibit hall afterwards. So I'm just going to allow us to have an open discussion here. Yanis, excellent talk on the future of IVUS. You know, people talk about, you know, contrasting IVUS and OCT, you know, which should you get? I mean, given the setting of HD IVUS, do you still need OCT or can it be completely replaced? Or any comment that you'd like to make? Yeah, so big, big debate. And I'm not quite sure there's a straight answer to this point. They both have their own advantages and disadvantages. Contrast used to be a disadvantage. Now with OCT now, it's also resolved. I believe that the combined catheter might have some future, but of course it comes with some price. It's still under development. The question is how much, and this is a bit philosophical, how much of this luxury we have with this extra features coming in, you know, in the field, how much this luxury is going to make an impact in our clinical practice? That's the number one. Number two, how much this additional information we get with the combined catheters can convince the physicians that it's a real need to use in clinical practice. So both, we're a group of stubborn people and I'm not quite sure we're very receptive to changes easily, but I believe at the same time, if you stay open-minded and if you would ask for my prediction, I believe that a very high definition IVUS catheter combined with OCT might have some good future here. Got him, I'm gonna ask you a question. I mean, we're seeing a number of more data coming back, going back to the question, IVUS versus physiology for lesion significance, both OCT and IVUS-based criteria for cutoffs. On that hot topic, what do you think, you know, if you had a choice between IVUS, you can do pre-PCI physiology and post-PCI physiology. You can do pre-PCI imaging and post-PCI imaging. Do, you know, some people advocate that we do both for optimal PCI. What is your take on that? I'm in agreement with you, Arnold. I think we should do both for optimal PCI. We should do pre-PCI physiology, post-PCI physiology, pre-PCI imaging, and post-PCI imaging. Now, I do realize that that is going to make your procedure longer a little bit, but, you know, if you have a procedural setup where this is your system, I think the important thing that Evan showed us is that no, it does not make your procedure longer. And, in fact, you might actually save some time. So, you know, the important thing is to get yourself into your workflow and say, okay, this is my efficiency of workflow. This is how I'm gonna do this. And then get your staff used to it, get your team to buy in on it. Now, to answer the second part of your question, which is IVUS or physiology, my answer is going to, well, actually imaging or physiology. Now, you know, we're getting into this traditional battle of form versus function. And I actually will take a step out there, a leap of faith, and say I think both are important because you're looking at different things in both. When you're looking at imaging, you're looking at things like stent apposition, you're looking at stent expansion, when you're looking at physiology, you're looking at what did I accomplish with these stents that I have put in. And you're not going to get that information from physiology alone. Now, if you're talking about imaging-based physiology with some of the more novel techniques on OCT that Evan's working on, for example, I think, yep, you may be able to get the physiology part of it, but then the controversy there is that is actually physiology that you're using. Dr. Curran and then Dr. Alton. Yeah, so I think that a couple of things, that if you're to do an approach, it would be to start the procedure with a pressure wire, work on the pressure wire, image your lesion, treat your lesion, leave your pressure wire, and at the end, you have your information. You had your post-imaging, post-pressure. It's a lot to ask for a group that barely does it now, but I think it is what should be done. The controversy about imaging versus physiology is a pseudo-controversy, because we're not talking about apples to apples, right? It's apples and oranges. And to equate a lumen area to a physiology result is nonsense, and it has always been nonsense, and every study has pointed to it being nonsense. That is, a four-millimeter cross-section area means something in one part of the vessel, but means nothing in another part of the vessel. So don't be confused. I don't think you guys are, but just to say, oh, I used one tool to get all the information. The only tool that's gonna have that might be an OCT physiology-derived, accurate imaging tool. So I wouldn't do it right now. I don't do it now. Physiology measures the flow, and imaging measures the structure. Get to it. So I think it's a great opportunity. So I'll turn it back to her. Yeah, so probably Evan's working on that OCT-based FFR, and there's already some papers on IVAS-based FFR as well. Dr. Alton, what do you think? Imaging, physiology, you've already had a great case where you've illustrated both. I mean, does this change any of your workflow currently in terms of using both? So, you know, we know that we should be treating patients who are symptomatic in one way, shape, or form. So if they have active ischemia, if they have evidence of hemodynamic ischemia. So I'm not necessarily gonna treat a lesion based on the IVAS appearance if it's not hemodynamically significant. So for me, the hemodynamic assessment is the decision point to intervene or not. And then the IVAS or the OCT is the necessary tool to accomplish a good result. Yeah, so the FUSION study is what we have been working on, we completed enrollment, it's in the analysis phase. So that's assessing an OCT-derived virtual physiology. So we look forward to seeing the results of that, and hopefully it'll be impactful. But I think it's just like with TAVR. You don't just look at a CT or just look at the T. It's incorporating everything. Fortunately, in the U.S., we have the ability to use multiple tools. And your responsibility, if you're implanting a prosthetic device in this patient, is to offer them the best tools. And the best outcome. And I think it's integrating these devices on a routine basis is what allows that. One of the things I'm most excited about for the future, and actually what you highlighted, is NIRS. I think it's one of the most underutilized, impactful imaging modalities. And it's not necessarily gonna be something that guides your PCI, but it completely changes your pharmacotherapy. When you see lipid-rich, vulnerable plaque, I think with PCSK9, there's been some really exciting data that came out in the past year showing how it completely changes the lesion when you put these patients on PCSK9 inhibitors. And I think there's a lot more work that needs to be done. And the more we utilize NIRS and identify these patients up front, because these are non-stenotic lesions. These are 20, 30% lesions. But we can change their pharmacotherapy. And you get that information when they're in the cath lab. And that's something, you know, I put in my cath report that this patient should be on a PCSK9 inhibitor. Otherwise, we'll see them back in the cath lab sometime in the near future. And I think that's exciting, what's on the horizon with vulnerable plaque. So I had a question from one of my distinguished panelists here. You know, the chlorofluorosystem is available. And I think Dr. Curran showed some nice slides on that. Now, the part that I'm struggling with and could be due to my own lack of knowledge is what is our impact on therapy in terms of, okay, we have a low CFR, what do we do? We have low IMR, what do we do? And I'm not talking about stenting. What's our impact on differences in medical therapy based on different scenarios and permutations of CFR and IMR? You want to talk about it? Yeah, I mean, I just want to make sure you recognize, of course, that there's the CORMICA trial, which is really a landmark trial from Dr. Ford, which really tried to identify the etiology of your mycobacterial disease and endothelial dysfunction and potentially direct therapy. It's the only trial that actually has shown that directed therapy can actually improve symptoms, which is a great challenge. So at Emory, there's Dr. Taleva, who's got a great program studying the microcirculation and directing therapy toward the one of many causes of a chest pain syndrome. So there's, you know, years ago, when we measured Doppler coronary flow, we didn't know what to do with it. All we could say was, Mrs. Smith, your normal coronary arteries are associated with good flow or microcirculatory impairment and bad flow, and that may be associated with your chest pain. But to give some reassurance initially, as a non-mechanical therapy worked pretty well. Now, there is no specific cure or treatment for mycobacterial disease because the etiologies are not so well understood. So I think it gives us an opportunity to learn more by using it more and eventually come up with therapy. Just one comment on potential therapy. Two rooms down right now, they're presenting data on coronary sinus reducer and its potential impact. So potential impact for microvascular disease. There's an ongoing study at the Mayo Clinic right now looking at, for patients with microvascular dysfunction, whether or not coronary sinus reducer potentially can help with symptoms. So I think that's something exciting in the near future, Tim. But the key was to have a tool that lets you measure coronary microvascular disease, right? Corventis is available today. And first is diagnosing it, there's pharmacotherapy for it, but potentially interventional treatment as well down the line. So just a quick question. It's a pretty good talk. And I listened to a few talks about imaging. The issue is, it's not only the procedure time that we need to consider here. It's also the financial of this, finances of this. So are we using this 100% of all PCI as we do here in the U.S.? We're adding 2,000 about, maybe even more, for each single PCI we do. Is our health system ready for that kind of cost? Great question. So Evan, I mean, is St. Francis going broke because they're using OCT every? We haven't gone out of business yet. So what's the cost of ISR? 10% of the time, patients come back. And I'll tell you, ISR, once you have ISR, it's associated in some studies as much as 50% mortality in five years. It's a terrible disease. You do worse with ISR than you do with most cancers. And the cost of the system for that is tremendous. So there's two large-scale studies that are gonna be looking at what's the economic impact. I think today, we don't have data to support that. But Illumine for 3,500 patients, looking at OCT versus angio-based PCI in a complex patient and complex lesions. There's an economic analysis of that. So in the next couple of years, we'll have that info. Simultaneously, the improved trial is looking at the exact same thing with intravascular ultrasound. So we're gonna have, between the two studies, 7,000 patients randomized with specific economic pre-specified outcomes that will hopefully, if they're both positive, I think change the guidelines and change reimbursement patterns. Because reimbursement is important because that's why in Japan, you have 90% intravascular imaging because it's reimbursed. So they can do appropriate treatment. Yeah, I think none of us have any doubt that imaging and physiology are both cost-effective and probably cost-saving for the healthcare system. And the challenge becomes, for the hospital, for the individual practitioner, is it gonna be reimbursement, is it positive, is it net margin? And that just gets back to advocating from Sky and others to enhance the reimbursement to appropriate quality measures. So it's already 748. I'm gonna encourage you guys to save your questions, come up to the audience, ask us anything. There's a moniker this week. And please visit the exhibit hall. I'd like to thank all the panelists and for their excellent talks. So thank you very much. Thank you. Good job.

intravascular ultrasound

optical coherence tomography

clinical practice

imaging technologies

PCI procedures