All right, so good morning, everybody. We switch gears here to imaging. The latest, HD iVOOS, near-infrared spectroscopy iVOOS, and then combined iVOOS and OCT. These are my disclosures. That's a bit of historical evolution of the iVOOS technology. It started initially with a 20 and 40 megahertz by Volcano, now Philips and Bosch Scientific, then VH. iVOOS, lately, within the last five years, we had the high-definition 60 megahertz iVOOS by Boston and Kodama, and also the combination of iVOOS with NIRS or with OCT. I'm going to walk you through the latest in the field, starting with the HD iVOOS. Very quickly, the most fundamental feature in imaging is called spatial resolution, and this refers essentially to the ability of the imaging to distinguish between two adjacent points. And that's essentially the rationale behind the HD iVOOS, which in terms of resolution is somewhere between the conventional 40 megahertz iVOOS and OCT. It's as close as possible to OCT, and at the same time, it maintains the very good depth, the traditional good depth with iVOOS, which is far superior than the OCT. So the high-definition iVOOS is somewhere essentially between the conventional iVOOS and OCT. We have two vendors engaged in this field, and a bit of anatomy, which essentially pertains to all iVOOS, but HD iVOOS gives us an opportunity to see even better the fibrous tissue, which is like white, bright, without shadow, the calcium with shadow, necrotic, or very, very echolucent, black kind of like thing, and then thrombus, which is usually in the gray zone. Now, clinical applications of HD iVOOS. Again, one can take the word HD and just keep the iVOOS there, but HD iVOOS helps us to do the job a bit better. So PCI planning first, things first. We can use iVOOS to essentially, in a way, substitute the invasive functional studies. The cutoff for non-left main plaques is 40 square millimeters, MLA. When it comes to left main, it's 60. Below 4.5 is definitely significant, and gray zone is 4526. Also, we use iVOOS, HD iVOOS even better, to find the landing zone, essentially the length of the stent, and also size, the diameter of the stent, find what the ideal diameter based on the distal reference point. Coming to the PCI optimization phase, stent expansion, opposition, dissection, and protrusion should be in our language after every PCI and using imaging, HD iVOOS, or any kind of iVOOS to optimize the result. And then in the long-term follow-up, we use imaging. HD iVOOS, in particular, can help us to assess the mechanism of pre-stenosis, whether it's in-stent stenosis or neotherosclerosis, and, of course, assess for stent fracture. Obviously, it's not the best modality, but still it can give us information. Going now to the near-infrared iVOOS. NIRS essentially quantifies the lipid burden within the atherosclerotic plaque. We create a map of the scanned angiogram. We call this chemogram. And the yellow spots, the yellow pools, correspond to the lipid content, the lipid pool within the scanned vessel. And we have this lipid core burden index, which quantifies the burden of the lipid material within the plaque. The LRP study, the lipid-rich plaque study, justified the use of NIRS as a clinical tool. A prospective study in 1,500 patients showing that the lipid core burden index can be a very good predictor of MACE events related to non-culprit lesions. Now, with this knowledge on board as well, the prospect study knowledge, which validated the plaque burden and the minimal lumen area as strong predictors of clinical outcomes, we now have the combination, essentially superimposition, of the lipid core burden on top of the plaque burden and of the MLA. And this combined information helps us to detect with higher accuracy the high-risk plaques, as shown in this study. Also, this combined information helps us to classify the high-risk plaques based on the lipid content information coming from the chemograms from the NIRS. And based on the calcium information coming from the IVUs, we can classify the plaques to rupture phenotypes, no calcium, lots of lipid, erosion phenotypes, no calcium, no lipid, and then calcified nodules, which are primarily full of calcium with limited lipid. Clinical applications of NIRS at this point are limited, but there's some future here. First of all, to detect the high-risk plaque, essentially engage downstream therapeutic pathways, potentially interventional for high-risk plaques to prevent future events. And of course, guidance for PCI strategy. We have sometimes echolucency in IVUs, and we don't know if this is a true lipid core or a shadow behind calcium. And obviously, calcium therapy versus lipid therapy is two different lesion preparation strategies. And then finally, concluding with the combination of IVUs with OCT, what's the rationale behind developing this tool? We know very well that IVUs has excellent depth, but the Achilles heel is the special resolution. OCT is great when it comes to resolution. However, it's poor with depth. So the ideal modality, one theoretically would say that is the combination of a tool that gives us great special resolution and great depth. And what's best than combining those technologies, those imaging modalities in a single catheter? Those are the available technologies in the market. The CONAVI system. Here's the IVUs, the simultaneous OCT of the same exact point in the coronary system, and then correlation with pathology. And that's the TERUMA system. Again, IVUs, OCT, and then superimposition. Very fascinating tools, but still ways to go. Clinical applications of combined IVUs, OCT, which is, I would say, in the infancy of this point is technology, first of all, to detect the high-risk plaques. IVUs gives us the plaque burden. OCT gives us the fibroscope thickness. The combination is very important for us to identify TIGFA, and then maybe downstream therapists, maybe interventional therapists will see how it's going to evolve. When it comes to PCI, pre-PCI we use IVUs, again, for lesion preparation and stent sizing and positioning. And then post-PCI, we need the best technology, OCT, to optimize the stent. And then same for left-man interventions with a particular focus here on the OCT to help us with rewiring, recrossing to the side branch. So to conclude, intra-coronary imaging is rapidly evolving with emphasis, first of all, on improving the resolution with HD-IVUs and OCT, and also with combining hybrid imaging with NIRS IVUs or IVUs-OCT. I would say that other than IVUs, the current IVUs modalities and OCT, most of the combined imaging modalities have currently no or limited clinical use. However, the future is bright, and the combined intra-coronary imaging modalities are anticipated to play a role, first of all, in the management of CAD, identification of high-risk plaque, and then also in terms of the planning and execution of PCIs. So I would like to thank you for your attention. Thank you.

intra-coronary imaging technology

High-Definition iVOUS

Near-Infrared Spectroscopy iVOUS

Optical Coherence Tomography

coronary artery disease