Well, again, thank you so much. My thanks to Sky for hosting this. It's great to be part of this fantastic and very inspirational seminar and panel. And so, I get to share with you some insights into calcium, which is, of course, our most important plaque compositional assessment in the cath lab when we're thinking about interventionally and we know the challenges of underestimating calcium. And with CT in our back pocket now, we really will have so much more greater insight into that. So, here's my disclosures. So, this audience has heard this already, CTA is growing. And so, I think there was a question in chat about alternatives in the cath lab, but I think that we are seeing this tool already being utilized for diagnosis. And so, when we have this incredibly powerful diagnostic imaging study ahead of time, non-invasively obtained, extracting it ahead of cath lab interventional work is absolutely appropriate. We've seen that testing has nearly doubled over the prior decade, and it's continuing to grow at quite an important bound, driven heavily by the ability to exclude non-obstructive coronary disease from the cath lab. But now, I think, as this seminar is really showing us, that we're kind of turning it into the other extreme about how do we do a better job in the cath lab. So, you've heard about this, I won't belabor this, but from the first two presentations really about there's so much available to us. This was a Carlos' overview presented in Jack Imaging a few years ago, that really there's, on the pre-procedural side, the intra-procedural side, there is so much to be gleaned from, as you heard about, from anatomy to physiology. So, why is it that it's important to just emphasize what we do with CT compared to angiography? Here's a typical angiogram, and really due to limitations of a 2D technique, which is an X-ray projection with limited contrast and really limited sensitivity to inherent calcium, it's easy to underestimate how much calcium there might be, for example, in this bifurcation lesion in the LAD. But on CT, we're not going to miss this. Standing across the room, we're going to see an incredible amount of calcium is really lining this fasculum. As soon as we see this, we might be, whoa, we're ready for something that's non-dilatable if we have to treat. Just an evolution here that between a classic conventional CT now to dual-source CT, we have improved some resolution, and this is even getting better with photon-counting CT, where now instead of really using a transformation of photons to light and then detecting it through kind of amazing detector technology, the photons themselves are being counted and detected. And therefore, this leads to a much higher resolution event. You can compare the two panels, left and right. And we're now able to see very fine plate-like calcium, spotty calcium here. The detail and the thickness is really evolving. This is an emerging technology, it's an expensive scanner, but as the future unfolds, I think we're going to have absolutely spectacular resolution capabilities about understanding calcium and atheroma. So CT really has this ability to detect various types of calcium. And as Carlos mentioned, as things age, we're going to see the development of spotty calcification. This is a micro-CT corresponding to histology, a really beautiful paper published last year for those who are interested in how the pathology really maps out here. But as we go from spotty as we age to fragments, this ultimately turns into sheet-like, and this is the one we associate more with non-dilatable calcium. Knowing this is here ahead of time, and we have this, you know, eventually, hopefully with photon counting CT, this type of resolution, it's really going to change our ability to pre-recognize these patients that are going to need calcium modification strategies. So again, the density really affects the age, and this is a slide borrowed from Dr. Collet. And I think, you know, we're going to learn. This is a fascinating concept about looking at density ahead of PCI. We don't have outcome studies yet, but I think it becomes clear that as we have harder and harder calcium, it doesn't take, you know, an incredible leap of faith to think that it's going to be harder to treat with just standard balloon-based strategies. So knowing this ahead of time, I think, will make us pivot earlier, as we heard about de-stressing the diagnostic aspects, or having us really be flexible ahead of time, because now we know what we're seeing. This is great. So we're going to move quickly from an early calcium strategy, where maybe we're thinking about balloons or specialized balloons, when we get into the mature strategies, we're going to think about, you know, greater calcium modification strategies like atherectomy and lithotripsy. One thing I thought that was really interesting, and this may be something that is paradoxical in terms of thinking about it, is that, believe it or not, there is a paradox with calcium density in clinical outcomes, and that it turns out that lower-density plaques are actually associated with higher MACE risks and higher plaque vulnerability. That's really probably driven by the fact that spotty calcification is a more pro-disruption phenotype. So this is really MACE risk for patients that are expecting to have an acute coronary syndrome, acute heart attack, sudden death. But I would posit to say that once someone needs interventional work in the cath lab, that it's actually quite the opposite, that the intensity, the density, the length, as we know, of the standard parameters, that's what really increases the complexity. And so I think we're going to see, as this happens, we're going to see emerging data – I'll present some just here recently published by colleagues – that higher density really does adversely affect our PCI strategies and outcomes. As you've seen, it's really well-matched, CTA, to look at calcium, and it's been compared to intravascular imaging in a number of different studies. We have a number of scores, driven really by Akiko Mahara and Seattle Lead Gary Mintz, both for IBIS and for OCT, trying to understand, by intravascular imaging, when do we really need to move to more advanced calcium modification strategies, such as atherectomy or lithotripsy. And literally the same thing is going to be happening from CT. As we've increased our resolution, we know we can measure calcium angle, we can see length, we can see thickness. We should start to be able to provide this up-front score, saying maybe it makes sense to consider up-front atherectomy, early atherectomy, before trying to kind of pound away with specialized balloons or noncompliant balloons and wrist dissections or ruptures. We see now that this really can be made similar to intravascular imaging readouts. We're used to cross-sectional axial images from IBIS and OCT. This can be really nicely done. We have, of course, 3D and curve planar reconstruction formats, which are great for looking at the longitudinal scope. But when we're looking at lesion planning, do we want to see this as 270, this is 360, we're just going to slice down this. And I think we'll have similar workflows, where we're just scrolling through the CT images at very high resolution. But we'll also have the overlay of density and thickness, hopefully automated for us. So when we integrate all of that, thickness, density, calcium, length, angle, that we're going to be able to hopefully have this automated, as Dr. Moran was mentioning. This will be kind of sent to the cloud and said, very high chance of non-dilatability, consider alternative strategies, such as atherectomy and lithotripsy. So what to do about significant calcium on CCTA? I think we know this, that this is an incredible tool, CT, to get us in the ballpark. But we are still at this phase where I think we should be using intravascular imaging liberally for PCI guidance in these sections to really confirm what we're seeing by CT. The co-registration with CT on axial images still needs to happen in real time. I think as we get more of that, maybe we won't need quite as much reliance on intravascular imaging, but we also don't have the outcomes. Hopefully the P4 trial is going to be a fantastic study to see how we do against intravascular imaging. And then, as we recognize the aging of our population, renal failure, diabetes, age, and longevity, and statin therapy, the calcification of coronary disease is continuing to evolve and grow. It is now so much more frequent as a prevalent part of our interventional practice that I think seeing this on CT immediately helps us kind of trigger about how important it is to really understand it. And therefore, I think we become more and more motivated to understand how to best use all the tools, master those, that are needed for calcium modification. Some emerging data for how CT is really modifying the interventional practice is just recently published using a simple calcium score based on high-density calcium, greater than 1,000 HF units, and a calcium arc greater than 180 degrees. And this was really an observational study, and when they went back and looked at their CT, they found that as density and calcium arc increase, greater PCI percentages needed calcium modification here. Not a surprise. But nice to have it ahead of time that, you know, if we know these scores are being validated, we're going to have this up front, again, decrease the cortical stress or worst-case scenario, you know, an initial dissection or perforation from non-modification strategies. And then, again, similarly, as the calcium score intensity goes up, there's just a greater reliance on things like cutting blue and lithotripsy atherectomy in this group. Sky has adopted this already in position papers, too, shown here on the references, but intravascular imaging is really step one. I think in this part here, we're talking about moderate severe coronary calcium by fluoroscopy. We're going to say by CT is going to be already here way ahead of time, and we're going to start to go in this category, and maybe P4 and other data will maybe even let us skip this step, and we'll start to utilize our approaches based on what we see with CT, either going to an atherectomy-based strategy or a cutting blue and scoring strategy. Again, motivation to really learn about all these tools and make sure that we've mastered them. We know that calcium modification is growing. It's spurred by intravascular imaging, and it has been spurred by the advent of intravascular lithotripsy, and also meeting the population demand. I think we just see more and more calcium in our coronary disease population at PCI. We now have great tools to deal with them, but there's still an underrecognition just with fluoroscopy and synangiography, and I think that's really going to diminish in these next years. So I'll just close by sharing that CCTA is an increasingly utilized tool for noninvasive assessment of coronary artery calcification, can help us avoid underrecognition of calcium, pre-identify PCI patients who need to advance calcium modification approaches. And pending further data from CCTA, we await the P4 trial and others, decision-making for calcium modification should also utilize intravascular imaging. And with that, I'm happy to pause and happy to take questions now during the discussion period. Wonderful. Thank you. Thanks again, Farouk. That was a very comprehensive review, and again, calcium is one of the big problems in the cath lab, especially in complex cases, and the more you plan, the better it is. One of the questions that came through in the chat is about the blooming artifact. You did show some nice images with photon counting, getting rid of it, but what is your current perception about this, and how much do you think is a problem? Sure. I think for calcium thickness, it's clearly a problem. I think we can do a good job with length and circumferential extent, two very important factors that we would, you know, utilize from IVAS, for example. As we move to higher-resolution CT approaches, dual-source and photon counting, we're going to start to address this as well. I think even those first two parameters, length and circumference, are very, very helpful ahead of a PCI approach. So Manos did my pitching here as well, so Farouk, congrats, that was a great presentation and took a number of notes also, some of the literature that you showed. So from my perspective, this is one of the important things for the interventional cardiologists, and we're not estranged to the fact that sometimes patients are sent to the lab with a severe lesion in the CT, and then you make a couple of shots in the lab, and you don't see any lesion. They say, oh, you know, the CT was wrong, you know, that's basically the reaction. And it relates to this blooming artifact, and this was one of the early learnings in the trial. And the reason why that happened, I'll tell you what I learned, is that when the radiologists or the imagers are acquiring the CT, they try to be very conservative or reduce the amount of radiation as much as they can. To achieve that, they reduce the voltage of the tube. And if you reduce the voltage of the tube, that basically creates a huge blooming artifact. So what we started doing in the trial from the, I think, the first 100, 200 cases was, if you see calcium, you cannot scan that patient with 80 kilovolts, which is kind of the standard of care for our young women with atypical complaints where the likelihood of CAD is very low. If you have a gentleman, 75-year-old with angina, and you're going to scan that patient, and you have calcium either in the calcium score or the other way, you have to increase the KBs, 220 at least. When you do that, Manos, you get a completely different picture of the calcium. You can get the information that I show during my presentation. You can get the information that was shown by Farouk, but you can really measure the arc. So it's also about understanding what are the technical things during the CT acquisition that are tailored for that particular patient, and that refers particularly to calcium. So this is kind of a learning process, not only for us in the catheter, but also for the people acquiring the CTs, where the question, again, is not anymore, is there a disease, yes or no? Is this a rule of test? No. The question is, I want to characterize the disease, and in the presence of calcium, you need to do a dedicated acquisition to be able to understand all these things that we have been talking about. Perfect. And I think that's one of the points that we as interventionalists don't often get involved in the acquisition of the scan. But this has been my experience with the, you know, we're very fortunate in our center that our imagers are extremely experienced. So from now on, when I ask, for example, for CTO planning, where calcium is almost always pleasant, but automatically, they tell the technicians, hey, light them up, increase the KEV, as you said, so the images we get are going to be of good diagnostic quality. So there is a little extra radiation dose, but I think that makes up the amount of data you get is well worth it and makes the planning way better. Jadav, Arashi, any thoughts before we move to the last presentation? No, I think Paulo said it well that, you know, there has to be clinical thought about which patient you are imaging and then accordingly change the settings. And I think for PCI planning, we will, you know, so for right now when I am getting CTs for pre-procedure planning, I make sure the photon count CT and the radiologist knows and everybody is so, so like what was Jadav said in the beginning of the thing, this is about networking and making sure, you know, you're communicating with all the key parties what you want so that they can deliver to you exactly what you need. I'll just say briefly that, I mean, the calcium blooming, it's a very important question. And I think there's something that will require a lot of education and communication across fields, you know, with the reference, the images and ourselves. But you know, the calcium arc, the length and the density that Carlos was alluding as well as Farouk, those are things that I think are strengths of CT. And also that you can do this for all coronaries, three vessels, so it is an asset. And I think all of us have cases and it actually follows perfectly with what Dr. Moran will present here in a minute. We've had cases I just had a couple of weeks ago that it was, you know, I could not cross an intravascular imaging catheter because it was severe calcification. So if I know the information beforehand, even better. So... Wonderful. Torres, I think you are now going to bring everything together with your case. So very excited to see your case. Thank you so much.

CT imaging

calcium management

coronary interventions

plaque composition

calcium modification strategies