1 00:00:00,080 --> 00:00:02,639 Hello, everyone. This is Erica Spicer Mason with 2 00:00:02,639 --> 00:00:04,960 Becker's Healthcare. Thank you so much for tuning 3 00:00:04,960 --> 00:00:07,379 into the Becker's Healthcare podcast series. 4 00:00:07,839 --> 00:00:10,019 So today we're going to talk about transforming 5 00:00:10,160 --> 00:00:12,500 coronary care and the future of cardiology. 6 00:00:13,244 --> 00:00:15,485 And joining me for this important conversation are 7 00:00:15,485 --> 00:00:17,565 two leaders from Baylor Scott and White, the 8 00:00:17,565 --> 00:00:18,304 heart hospital. 9 00:00:19,005 --> 00:00:21,344 We have with us doctor Amro Al Said, 10 00:00:21,484 --> 00:00:24,064 medical director of advanced cardiac imaging, 11 00:00:24,524 --> 00:00:27,484 and doctor Karim Al Azizi, medical director of 12 00:00:27,484 --> 00:00:30,149 the cath lab and structural heart disease program. 13 00:00:30,769 --> 00:00:33,329 Doctor Al Said, doctor Al Azizi, welcome, and 14 00:00:33,329 --> 00:00:34,770 thank you so much for making time for 15 00:00:34,770 --> 00:00:35,510 this today. 16 00:00:35,890 --> 00:00:37,810 Thank you, Erica. Great to be here. Thank 17 00:00:37,810 --> 00:00:38,950 you for having us. 18 00:00:39,810 --> 00:00:41,489 Really, really happy to have you both on 19 00:00:41,489 --> 00:00:44,085 the podcast. And before we get into the 20 00:00:44,085 --> 00:00:46,325 heart of the conversation today, didn't mean to 21 00:00:46,325 --> 00:00:47,844 make that pun, but I guess I just 22 00:00:47,844 --> 00:00:48,344 did. 23 00:00:49,045 --> 00:00:50,484 I would love to learn just a little 24 00:00:50,484 --> 00:00:51,945 bit more about you both. 25 00:00:52,405 --> 00:00:54,164 Just if you wouldn't mind sharing a little 26 00:00:54,164 --> 00:00:55,765 bit more about your background in health care, 27 00:00:55,765 --> 00:00:57,719 your organization, whatever you think is helpful for 28 00:00:57,719 --> 00:00:59,020 our listeners to know. 29 00:00:59,399 --> 00:01:01,640 Doctor Alsa, you may you could get us 30 00:01:01,640 --> 00:01:02,140 started. 31 00:01:02,840 --> 00:01:05,159 Yes. So, as you mentioned, I am a 32 00:01:05,159 --> 00:01:09,020 cardiologist with subspecialty training in multimodality advanced cardiac 33 00:01:09,079 --> 00:01:12,140 imaging. My current role as the director of, 34 00:01:12,564 --> 00:01:14,984 advanced cardiac imaging at the Heart Hospital. 35 00:01:15,525 --> 00:01:16,665 I, basically, 36 00:01:17,284 --> 00:01:20,025 oversee the operations at multiple campuses, 37 00:01:20,405 --> 00:01:23,144 for the enterprise, and I oversee things from 38 00:01:23,364 --> 00:01:25,224 quality, hardware, and software 39 00:01:25,750 --> 00:01:27,289 selection, workflow optimization, 40 00:01:27,750 --> 00:01:29,849 and patient access to advanced imaging. 41 00:01:30,310 --> 00:01:32,890 I'm also routinely involved in AI integration, 42 00:01:33,269 --> 00:01:34,810 research, and fellow education. 43 00:01:35,989 --> 00:01:37,750 Wonderful. It's great to have you with us, 44 00:01:37,750 --> 00:01:40,149 doctor Al Sayed. And doctor Al Azizi, how 45 00:01:40,149 --> 00:01:42,805 about you? Yeah. I'm an interventional cardiologist, 46 00:01:43,105 --> 00:01:45,825 by training. I specialize in structural heart disease 47 00:01:45,825 --> 00:01:48,484 interventions as well as complex coronary interventions. 48 00:01:49,105 --> 00:01:51,105 I did train with doctor Al Said, 49 00:01:51,505 --> 00:01:52,784 specifically on CT, 50 00:01:53,880 --> 00:01:55,319 imaging back in training. But, 51 00:01:55,959 --> 00:01:58,859 more importantly, my my role, in the organization 52 00:01:58,920 --> 00:02:01,319 is to oversee again a lot of the 53 00:02:01,319 --> 00:02:04,459 workflows, algorithms, as well as, quality, 54 00:02:05,400 --> 00:02:06,439 assessment of, 55 00:02:06,840 --> 00:02:08,780 our work, in the cath lab 56 00:02:09,105 --> 00:02:11,504 and as well as the structural heart program 57 00:02:11,504 --> 00:02:12,245 in Plano. 58 00:02:12,705 --> 00:02:15,025 And with that, obviously, we work very closely 59 00:02:15,025 --> 00:02:18,085 together between, you know, our departments, our operational 60 00:02:18,145 --> 00:02:20,465 departments, and the imaging department, as you can 61 00:02:20,465 --> 00:02:22,784 imagine, to streamline a lot of the clinical 62 00:02:22,784 --> 00:02:23,639 work that we do. 63 00:02:25,080 --> 00:02:27,800 Fantastic. Doctor Alazizi, thank you so much. And 64 00:02:27,800 --> 00:02:29,879 it's just great to have the expertise from 65 00:02:29,879 --> 00:02:32,039 the two of you for this conversation and 66 00:02:32,039 --> 00:02:34,039 also great to know that you worked with 67 00:02:34,039 --> 00:02:36,199 each other previously. So I think this is 68 00:02:36,199 --> 00:02:38,219 bound to be a a great discussion. 69 00:02:38,794 --> 00:02:40,414 And I wanted to start off by 70 00:02:40,715 --> 00:02:42,875 really touching on this trend that we're seeing 71 00:02:42,875 --> 00:02:45,854 in cardiology, and that is really this significant 72 00:02:45,914 --> 00:02:46,414 demand, 73 00:02:47,275 --> 00:02:50,074 across across the industry, and it's continuing to 74 00:02:50,074 --> 00:02:52,474 grow as well. So in this environment of 75 00:02:52,474 --> 00:02:53,215 high demand, 76 00:02:53,689 --> 00:02:56,490 what key challenges has your department faced? I 77 00:02:56,490 --> 00:02:58,330 would love for both of you to, to 78 00:02:58,330 --> 00:02:59,310 elaborate on that. 79 00:03:00,169 --> 00:03:02,990 So I can start. And, it's it's really 80 00:03:03,770 --> 00:03:06,409 the initial challenge or opportunities that we've had 81 00:03:06,409 --> 00:03:08,189 in imaging has been largely 82 00:03:08,715 --> 00:03:11,514 about how we diagnose coronary artery disease. So, 83 00:03:11,754 --> 00:03:14,395 for decades, our approach for detecting coronary artery 84 00:03:14,395 --> 00:03:17,115 disease has been largely indirect. So we relied 85 00:03:17,115 --> 00:03:20,314 in surrogates of, flow limiting stenosis rather than 86 00:03:20,314 --> 00:03:21,775 direct disease visualization. 87 00:03:22,460 --> 00:03:25,840 We've used things like symptoms and exercise testing 88 00:03:26,219 --> 00:03:28,620 as proxies for risk. And the logic was 89 00:03:28,620 --> 00:03:31,120 if symptoms or signs of stress induced ischemia 90 00:03:31,260 --> 00:03:33,599 appear, then there must be significant narrowing. 91 00:03:33,900 --> 00:03:36,060 But this model, what the problem is with, 92 00:03:36,300 --> 00:03:38,319 with the is the detects late disease 93 00:03:38,754 --> 00:03:41,394 and, when the problems in coronary artery disease 94 00:03:41,394 --> 00:03:42,455 is already advanced. 95 00:03:43,155 --> 00:03:43,894 Then historically, 96 00:03:44,435 --> 00:03:46,834 calcium scoring had been used as the corner 97 00:03:46,834 --> 00:03:50,694 score stone for early detection. It's convenient, reproducible, 98 00:03:51,259 --> 00:03:52,379 but it doesn't really, 99 00:03:52,939 --> 00:03:56,139 measure active disease. It's more of a, a 100 00:03:56,139 --> 00:03:58,620 marker for chronicity of the disease rather than 101 00:03:58,620 --> 00:04:01,500 active disease. And we have seen this from 102 00:04:01,500 --> 00:04:03,794 from national data when you look at over 103 00:04:03,794 --> 00:04:04,775 four and a half million, 104 00:04:05,395 --> 00:04:08,055 patients in The US who presented with ACA 105 00:04:08,354 --> 00:04:09,555 ACS in the past, 106 00:04:10,675 --> 00:04:11,895 seven to eight years. 107 00:04:12,514 --> 00:04:13,974 Half of them were asymptomatic 108 00:04:14,354 --> 00:04:16,455 when they first presented with ACS. 109 00:04:16,915 --> 00:04:19,449 Twenty two percent of them had a coronary 110 00:04:19,449 --> 00:04:21,689 calcium score of zero. So these are people 111 00:04:21,689 --> 00:04:24,670 who would have been missed by traditional markers 112 00:04:24,810 --> 00:04:25,310 of, 113 00:04:26,170 --> 00:04:28,350 of risk stratification, if you will. 114 00:04:28,889 --> 00:04:31,290 Almost one in five did not even seek, 115 00:04:32,089 --> 00:04:34,029 a primary care physician visits. 116 00:04:34,444 --> 00:04:37,805 So despite of, decades of emphasis of risk 117 00:04:37,805 --> 00:04:41,084 factors and calcium scoring, we're still missing a 118 00:04:41,084 --> 00:04:42,944 large populations of patients 119 00:04:43,324 --> 00:04:46,464 that have silent disease and biologically active disease. 120 00:04:46,930 --> 00:04:47,410 Now, 121 00:04:47,889 --> 00:04:49,750 when you look at this again, the ACC 122 00:04:50,689 --> 00:04:53,730 chest pain guidelines, rightfully so, they had made 123 00:04:53,730 --> 00:04:54,709 the coronary CTA, 124 00:04:55,250 --> 00:04:58,529 the first class one indication for addressing patient 125 00:04:58,529 --> 00:05:00,389 with acute chest pain. 126 00:05:00,845 --> 00:05:04,144 But this had led to a rapid adoption 127 00:05:04,285 --> 00:05:07,884 and, which is great. But, then come another 128 00:05:07,884 --> 00:05:10,204 another challenge, and that was the shortage of 129 00:05:10,204 --> 00:05:11,664 experienced CT readers. 130 00:05:12,204 --> 00:05:15,185 Again, training pathway for CTA had been historically 131 00:05:15,485 --> 00:05:18,040 very variable. It was from one week courses, 132 00:05:18,420 --> 00:05:19,720 and virtual courses 133 00:05:20,100 --> 00:05:22,100 to one to two years of advanced imaging 134 00:05:22,100 --> 00:05:24,439 fellowship. And that's where I think AI, 135 00:05:24,899 --> 00:05:27,300 based platform, something like Clearly, where it comes 136 00:05:27,300 --> 00:05:29,800 in where it can provide us with automated 137 00:05:30,100 --> 00:05:30,920 and reproducible 138 00:05:31,794 --> 00:05:35,235 stenosis assessment and functional assessment and then adds 139 00:05:35,235 --> 00:05:36,935 the piece of plaque quantification. 140 00:05:38,035 --> 00:05:40,354 Again, it does not replace the physician, but 141 00:05:40,354 --> 00:05:41,495 it really elevates, 142 00:05:42,354 --> 00:05:43,095 the availability 143 00:05:43,474 --> 00:05:44,774 of readers. And 144 00:05:45,129 --> 00:05:48,009 if you may democratize the presence of, 145 00:05:48,970 --> 00:05:51,370 high quality reefs even in places that are 146 00:05:51,370 --> 00:05:52,910 not tertiary care centers. 147 00:05:53,370 --> 00:05:55,449 And I'll stop here probably, let doctor Al 148 00:05:55,449 --> 00:05:56,985 Azizi talk about what the, 149 00:05:57,544 --> 00:06:00,584 procedural size in cath lab access challenges have 150 00:06:00,584 --> 00:06:01,084 been. 151 00:06:01,784 --> 00:06:03,144 Yeah. I I mean, you know, to add 152 00:06:03,144 --> 00:06:04,824 to this, and you can imagine that the 153 00:06:04,824 --> 00:06:07,724 the downstream effect of this, obviously, diagnostic 154 00:06:08,104 --> 00:06:11,224 tools and and, tests have increased significantly over 155 00:06:11,224 --> 00:06:14,399 the years. Coronary CTA has been adopted widely. 156 00:06:14,779 --> 00:06:17,279 Once used to be an issue in getting 157 00:06:17,660 --> 00:06:19,740 prior authorization to try to get it through 158 00:06:19,740 --> 00:06:20,800 whether it's outpatient, 159 00:06:21,339 --> 00:06:23,759 obviously, now being more acceptable in the inpatient 160 00:06:23,819 --> 00:06:24,319 side. 161 00:06:24,805 --> 00:06:26,564 But that has also led to a lot 162 00:06:26,564 --> 00:06:28,925 of unknowns and a lot of questions and 163 00:06:28,925 --> 00:06:31,044 a lot of potentially even trips to the 164 00:06:31,044 --> 00:06:33,604 cath lab, but also kept other people out 165 00:06:33,604 --> 00:06:36,104 of the cath lab. What was once considered 166 00:06:36,164 --> 00:06:38,084 that, you know, patients would have to land 167 00:06:38,084 --> 00:06:40,345 on the table were less likely to see 168 00:06:40,810 --> 00:06:41,310 diagnostic 169 00:06:41,689 --> 00:06:43,389 procedures done on the table 170 00:06:43,930 --> 00:06:45,769 just because of the fact that those patients 171 00:06:45,769 --> 00:06:48,810 were appropriately deferred and steered away from the 172 00:06:48,810 --> 00:06:51,129 cath lab what was once going to the 173 00:06:51,129 --> 00:06:53,050 cath lab. And so we're more likely to 174 00:06:53,050 --> 00:06:54,350 get to more interventions 175 00:06:54,889 --> 00:06:55,550 and more 176 00:06:56,014 --> 00:06:56,514 therapeutic, 177 00:06:57,295 --> 00:06:59,074 procedures rather than perhaps, 178 00:06:59,935 --> 00:07:00,995 diagnostic procedures. 179 00:07:01,535 --> 00:07:04,335 On that note and how important this topic 180 00:07:04,335 --> 00:07:06,035 is, if you look at the opening 181 00:07:06,495 --> 00:07:06,995 conference 182 00:07:07,535 --> 00:07:10,274 lecture at TCT, which is our largest interventional 183 00:07:11,410 --> 00:07:13,810 conference that happens every year and just happened 184 00:07:13,810 --> 00:07:15,349 in, San Francisco. 185 00:07:16,050 --> 00:07:16,789 Our opening, 186 00:07:17,250 --> 00:07:20,209 you know, title for the opening session is 187 00:07:20,209 --> 00:07:22,389 I have an abnormal coronary CTA. 188 00:07:22,689 --> 00:07:25,344 What do I do now? And so this 189 00:07:25,344 --> 00:07:26,564 trickles into revascularization. 190 00:07:27,024 --> 00:07:29,425 This trickles into prevention. This trickles into many 191 00:07:29,425 --> 00:07:31,125 things. But long story short, 192 00:07:31,664 --> 00:07:33,664 this as an as a utility as a 193 00:07:33,664 --> 00:07:36,384 tool essentially to detect disease has allowed us 194 00:07:36,384 --> 00:07:38,580 to get to those patients sooner, has allowed 195 00:07:38,580 --> 00:07:41,720 to ease the conversation from prevention and secondary 196 00:07:41,779 --> 00:07:44,660 prevention, obviously, if they have plaque. And also, 197 00:07:44,660 --> 00:07:47,319 more importantly, has allowed us to defer appropriately 198 00:07:47,459 --> 00:07:48,980 patients that did not need to come to 199 00:07:48,980 --> 00:07:50,439 the cath lab with non cardiac, 200 00:07:50,980 --> 00:07:51,720 chest pain, 201 00:07:52,384 --> 00:07:54,305 and choose the ones that are appropriate to 202 00:07:54,305 --> 00:07:57,585 come to the cath lab for further, workup 203 00:07:57,585 --> 00:07:58,564 and intervention. 204 00:08:00,465 --> 00:08:02,705 I I really appreciate the overview, doctor Al 205 00:08:02,705 --> 00:08:04,850 Azizi and doctor Al Said. It sounds like 206 00:08:04,850 --> 00:08:06,529 some of the challenges that you're up against 207 00:08:06,529 --> 00:08:09,430 really boil down to challenges in patient identification, 208 00:08:10,770 --> 00:08:12,230 experiencing missed patients, 209 00:08:12,850 --> 00:08:15,350 some gaps in training competencies and quality, 210 00:08:15,889 --> 00:08:18,125 and also access. But at the same time, 211 00:08:18,125 --> 00:08:20,444 I'm also hearing some opportunities that you're both 212 00:08:20,444 --> 00:08:23,324 sharing here, whether that's a more upstream and 213 00:08:23,324 --> 00:08:26,045 preventative approach in care. And then also doctor 214 00:08:26,045 --> 00:08:27,564 Al Said, I know you touched on AI 215 00:08:27,564 --> 00:08:28,704 briefly as well. 216 00:08:29,099 --> 00:08:31,180 So I'd like to go there next. Amid 217 00:08:31,180 --> 00:08:33,659 some of these challenges, how has Baylor Scott 218 00:08:33,659 --> 00:08:36,379 and White, the heart hospital, leveraged tech to 219 00:08:36,379 --> 00:08:38,559 drive clinical efficiencies and improvements? 220 00:08:39,179 --> 00:08:40,559 And could you share an example? 221 00:08:41,595 --> 00:08:44,315 Yes. Absolutely. So when I reflect on our 222 00:08:44,315 --> 00:08:46,815 local campus here over the past three years, 223 00:08:47,115 --> 00:08:49,674 so we have transitioned again. We adopted coronary 224 00:08:49,674 --> 00:08:51,054 CTA, and we have transitioned 225 00:08:51,514 --> 00:08:53,914 that we now utilize coronary CTA in nearly 226 00:08:53,914 --> 00:08:54,815 90% 227 00:08:54,875 --> 00:08:57,910 of our day to day CAD testing. So, 228 00:08:58,309 --> 00:09:00,950 our volume have went up from about 8,000 229 00:09:00,950 --> 00:09:03,269 coronary CTAs a year to over, 230 00:09:03,750 --> 00:09:04,629 20,000 231 00:09:04,629 --> 00:09:07,690 coronary CTAs a year. And this is, again, 232 00:09:07,750 --> 00:09:11,029 really a testament about, the opportunities that you 233 00:09:11,029 --> 00:09:13,105 can scale this testing modality, 234 00:09:14,125 --> 00:09:15,264 even when you have 235 00:09:16,284 --> 00:09:17,904 relatively stable resources. 236 00:09:18,365 --> 00:09:20,445 If you compare that to a cath lab, 237 00:09:20,445 --> 00:09:21,985 in order for you to scale, 238 00:09:22,605 --> 00:09:25,424 such a huge volume, it will require a 239 00:09:25,884 --> 00:09:26,784 much larger 240 00:09:27,710 --> 00:09:28,930 resources utilization. 241 00:09:29,710 --> 00:09:31,809 And what we've done is that we've implemented 242 00:09:32,430 --> 00:09:35,389 AI tools, like like the platform, the Clearloop 243 00:09:35,389 --> 00:09:35,889 platform, 244 00:09:36,430 --> 00:09:39,950 across the selected CTAs to, study. So what 245 00:09:39,950 --> 00:09:42,014 it helped us do is that it allowed 246 00:09:42,014 --> 00:09:44,835 us to standardize assessment of the luminal stenosis, 247 00:09:45,054 --> 00:09:48,595 whether a moderate stenosis is functionally significant, 248 00:09:49,534 --> 00:09:52,495 and quantify the plaque type of burden, which 249 00:09:52,495 --> 00:09:55,290 has been the recent addition to our tools 250 00:09:55,290 --> 00:09:57,309 for, magic coronary artery disease. 251 00:09:57,929 --> 00:09:58,170 And, 252 00:09:58,970 --> 00:10:00,250 really, it allowed us, 253 00:10:00,809 --> 00:10:02,649 when we were in a large system that 254 00:10:02,649 --> 00:10:03,149 has, 255 00:10:03,769 --> 00:10:05,070 maybe 20 readers, 256 00:10:05,690 --> 00:10:09,524 across different, experience levels, it allows us to, 257 00:10:10,004 --> 00:10:12,425 maintain a certain level of, quality 258 00:10:12,884 --> 00:10:14,184 across the the different 259 00:10:14,725 --> 00:10:18,085 readers. And, it gave us opportunities for quality 260 00:10:18,085 --> 00:10:19,865 checks, areas for improvement. 261 00:10:20,485 --> 00:10:20,805 And, 262 00:10:21,365 --> 00:10:21,865 additionally, 263 00:10:22,884 --> 00:10:23,945 this fast turnaround 264 00:10:24,330 --> 00:10:27,210 time in under two hours for the processing 265 00:10:27,210 --> 00:10:27,950 of studies 266 00:10:28,410 --> 00:10:29,210 allowed us to, 267 00:10:30,009 --> 00:10:32,970 streamline processes like acute chest pain for ER 268 00:10:32,970 --> 00:10:36,590 presentation. Aside from inpatient, outpatient, triaging patients, 269 00:10:36,970 --> 00:10:39,070 we we started the program where, 270 00:10:39,504 --> 00:10:41,824 it takes less than three hours from the 271 00:10:41,824 --> 00:10:43,924 time that the patient present to the emergency 272 00:10:43,985 --> 00:10:47,125 room until we have a decision at disposition. 273 00:10:47,424 --> 00:10:49,204 At that time, they would have gotten, 274 00:10:49,745 --> 00:10:51,044 their EKG, troponins, 275 00:10:51,584 --> 00:10:52,084 and 276 00:10:52,799 --> 00:10:55,519 CT with functional assessment at that time. So 277 00:10:55,519 --> 00:10:57,600 you have a clear plan and pathway for 278 00:10:57,600 --> 00:11:00,100 them, and you do not need additional testing. 279 00:11:01,039 --> 00:11:02,179 This what have been, 280 00:11:03,279 --> 00:11:04,019 our utilization 281 00:11:04,559 --> 00:11:07,585 of this. And then more recently with, like, 282 00:11:07,585 --> 00:11:10,565 collaboration with our interventional colleagues like Pedro Azizi, 283 00:11:10,865 --> 00:11:11,985 we're able to, 284 00:11:12,384 --> 00:11:14,544 take this a step further that when we 285 00:11:14,544 --> 00:11:15,684 identify disease, 286 00:11:16,065 --> 00:11:17,985 how do we plan the this, 287 00:11:18,625 --> 00:11:19,125 procedure? 288 00:11:19,504 --> 00:11:20,804 Where do we do these, 289 00:11:21,419 --> 00:11:23,200 procedures and take really, 290 00:11:23,659 --> 00:11:26,000 an additional step in looking at this. 291 00:11:27,019 --> 00:11:29,339 So insightful, doctor Al Said. Thank you so 292 00:11:29,339 --> 00:11:31,500 much. And doctor Al Azizi, I'd be curious 293 00:11:31,500 --> 00:11:33,279 to know too if if you have any, 294 00:11:34,014 --> 00:11:36,014 other outcomes that you'd add as a result 295 00:11:36,014 --> 00:11:37,554 of this AI driven approach, 296 00:11:37,934 --> 00:11:40,654 especially from the patient care experience. Would love 297 00:11:40,654 --> 00:11:43,534 to to touch on any outcomes you've seen 298 00:11:43,534 --> 00:11:44,034 there. 299 00:11:44,735 --> 00:11:46,254 Yeah. I think I think to add to 300 00:11:46,254 --> 00:11:48,210 what doctor Al Said mentioned and to dive 301 00:11:48,210 --> 00:11:49,889 a little bit further, right now, if you 302 00:11:49,889 --> 00:11:50,629 look at 303 00:11:51,009 --> 00:11:53,649 how much of PCI is being done outside 304 00:11:53,649 --> 00:11:55,889 the hospital, it's quite a bit. And a 305 00:11:55,889 --> 00:11:58,230 lot of it is being done safely with 306 00:11:58,290 --> 00:12:01,090 very good outcomes. But reality is, as we 307 00:12:01,090 --> 00:12:02,929 do more of these, we are able to 308 00:12:02,929 --> 00:12:05,394 detect things that we don't want to be 309 00:12:05,394 --> 00:12:07,235 surprised with on the cat on the table 310 00:12:07,235 --> 00:12:09,554 in the cath lab, which will involve severe 311 00:12:09,554 --> 00:12:13,014 calcification that require atherectomy devices, which will involve, 312 00:12:14,115 --> 00:12:15,815 lithotripsy, which will involve, 313 00:12:16,274 --> 00:12:20,169 potentially mechanical circulatory support or whatever it may 314 00:12:20,169 --> 00:12:21,070 be that will 315 00:12:21,690 --> 00:12:24,269 essentially take you from a, you know, unrevascularized, 316 00:12:25,289 --> 00:12:27,070 territories to a complete revascularization. 317 00:12:27,449 --> 00:12:29,389 No one wants to do a bad job, 318 00:12:29,449 --> 00:12:31,209 but everyone wants to do a good job 319 00:12:31,209 --> 00:12:33,289 in an appropriate setting. So in the in 320 00:12:33,289 --> 00:12:35,875 the hospital setting, for example, you're more likely 321 00:12:35,875 --> 00:12:38,355 to use a rotational atherectomy. You're more likely 322 00:12:38,355 --> 00:12:39,334 to do advanced 323 00:12:39,875 --> 00:12:40,375 procedures 324 00:12:40,834 --> 00:12:43,235 given the fact that potentially you have surgical 325 00:12:43,235 --> 00:12:45,394 backup and you have all the tools next 326 00:12:45,394 --> 00:12:47,794 to you. Whereas, for example, in OBLs or 327 00:12:47,794 --> 00:12:49,495 ambulatory surgical centers, 328 00:12:49,875 --> 00:12:52,070 you are not really on an island, but 329 00:12:52,070 --> 00:12:54,230 you're really not taking on any high risk 330 00:12:54,230 --> 00:12:56,870 cases. And so the the beauty of, data 331 00:12:56,870 --> 00:12:59,049 that you can collect from the coronary CTA 332 00:12:59,429 --> 00:13:01,830 and specifically with solutions like this is that 333 00:13:01,830 --> 00:13:03,610 it can tell you the degree of calcification, 334 00:13:04,254 --> 00:13:05,235 length of disease, 335 00:13:05,615 --> 00:13:06,674 understand bifurcation, 336 00:13:07,454 --> 00:13:07,954 involvement, 337 00:13:09,214 --> 00:13:11,634 even taking it a step further in planning 338 00:13:11,934 --> 00:13:14,814 chronic total occlusion PCI, which is obviously done 339 00:13:14,814 --> 00:13:17,134 in the hospital. I think number one, you 340 00:13:17,134 --> 00:13:19,774 triage the patient appropriately to be treated in 341 00:13:19,774 --> 00:13:21,820 the right setting in order to give them 342 00:13:21,820 --> 00:13:23,679 the best chance for the best redascularization. 343 00:13:24,059 --> 00:13:26,379 Number two, actually go in with a plan. 344 00:13:26,379 --> 00:13:28,379 And that's one thing that doctor Al Said 345 00:13:28,379 --> 00:13:30,139 and I and many others around the country 346 00:13:30,139 --> 00:13:32,720 have really tried to work on a prescriptive 347 00:13:32,940 --> 00:13:34,959 way in order to translate 348 00:13:35,845 --> 00:13:36,904 the CT data 349 00:13:37,284 --> 00:13:39,065 from softwares like this 350 00:13:39,524 --> 00:13:41,524 onto what we are able to apply in 351 00:13:41,524 --> 00:13:42,804 the cath lab and really go in with 352 00:13:42,804 --> 00:13:44,345 a plan. If you look at a pilot, 353 00:13:44,404 --> 00:13:46,325 no pilot flies out without a plan. And 354 00:13:46,325 --> 00:13:48,245 I think more and more and even as 355 00:13:48,245 --> 00:13:48,904 a structuralist, 356 00:13:49,524 --> 00:13:50,345 when AMRO 357 00:13:50,769 --> 00:13:52,610 refers to me a patient and we're talking 358 00:13:52,610 --> 00:13:54,450 about a CT from a planning and structural 359 00:13:54,450 --> 00:13:56,529 heart space, nobody goes in into a structural 360 00:13:56,529 --> 00:13:58,230 procedure without CT planning, 361 00:13:58,690 --> 00:13:59,829 specifically TAVRs. 362 00:14:00,209 --> 00:14:03,169 But this should also translate to complex coronary, 363 00:14:03,169 --> 00:14:05,570 which honestly, the room for error is very, 364 00:14:05,570 --> 00:14:06,309 very small. 365 00:14:06,634 --> 00:14:07,455 And the outcomes, 366 00:14:07,914 --> 00:14:10,075 are very, very important in in making sure 367 00:14:10,075 --> 00:14:12,394 that the patients not only get a good 368 00:14:12,394 --> 00:14:14,554 acute outcome, but a more durable outcome. And 369 00:14:14,554 --> 00:14:16,575 that is all really dictated by procedural, 370 00:14:17,355 --> 00:14:19,674 planning and what I think or what I 371 00:14:19,674 --> 00:14:22,335 call patient triaging to the appropriate setting. 372 00:14:23,660 --> 00:14:26,379 Yeah. I appreciate the the add ons, doctor 373 00:14:26,379 --> 00:14:27,039 Al Azizi. 374 00:14:27,419 --> 00:14:29,660 Triaging to the patient to the appropriate setting, 375 00:14:29,660 --> 00:14:31,340 I know that goes a long way from 376 00:14:31,340 --> 00:14:33,660 a clinical and operational standpoint and also in 377 00:14:33,660 --> 00:14:36,539 terms of, you know, reducing friction for patients 378 00:14:36,539 --> 00:14:38,080 as well as they're moving through 379 00:14:38,424 --> 00:14:41,304 potentially a difficult test finding or or something 380 00:14:41,304 --> 00:14:42,125 of that nature. 381 00:14:42,745 --> 00:14:45,465 I really appreciate how you both have highlighted 382 00:14:45,465 --> 00:14:47,065 some of the benefits that you're seeing with 383 00:14:47,065 --> 00:14:47,804 this approach. 384 00:14:48,184 --> 00:14:49,804 You know, having AI and technology 385 00:14:50,360 --> 00:14:52,920 help with some of these inefficiencies. And I'm 386 00:14:52,920 --> 00:14:55,160 I'm sure that there are other cardiology departments 387 00:14:55,160 --> 00:14:56,940 across the country that are considering 388 00:14:57,320 --> 00:14:58,379 a similar implementation 389 00:14:58,840 --> 00:15:00,600 to keep up with demand and to get 390 00:15:00,600 --> 00:15:02,200 patients to the right place at the right 391 00:15:02,200 --> 00:15:02,700 time. 392 00:15:03,195 --> 00:15:05,595 What practical next steps or advice would you 393 00:15:05,595 --> 00:15:08,315 offer for those organizations who are considering a 394 00:15:08,315 --> 00:15:09,215 similar approach? 395 00:15:10,154 --> 00:15:13,035 I would start with quality. I think, the 396 00:15:13,035 --> 00:15:15,449 the really, it is the foundation having a 397 00:15:15,449 --> 00:15:17,629 quality study and initial investments 398 00:15:18,009 --> 00:15:19,709 in in in adequate hardware, 399 00:15:20,250 --> 00:15:21,549 should be the the cornerstone 400 00:15:22,089 --> 00:15:23,049 of, any, 401 00:15:23,370 --> 00:15:25,389 CT based program across the country. 402 00:15:26,009 --> 00:15:28,409 Historically, I would say, there have been a 403 00:15:28,409 --> 00:15:32,985 limitation or initial entry fear from, hospitals that, 404 00:15:34,105 --> 00:15:36,365 it requires a very high end 405 00:15:36,904 --> 00:15:39,544 technology or hardware to be able to have 406 00:15:39,544 --> 00:15:42,105 a coronary CTA program. This is no longer 407 00:15:42,105 --> 00:15:44,284 the case. The majority of the coronary CTAs 408 00:15:44,345 --> 00:15:44,940 that are, 409 00:15:45,500 --> 00:15:46,000 diagnostic 410 00:15:46,460 --> 00:15:48,159 and something that we can use, 411 00:15:48,940 --> 00:15:50,480 with with the Clearly platform, 412 00:15:51,259 --> 00:15:51,659 are, 413 00:15:52,139 --> 00:15:54,080 done on bread and butter, 414 00:15:54,940 --> 00:15:58,460 hardware. But, the additional point that I think 415 00:15:58,460 --> 00:15:59,279 it's an 416 00:15:59,659 --> 00:16:02,084 initial step that we need to focus on 417 00:16:02,144 --> 00:16:04,084 is having an investment in, 418 00:16:04,865 --> 00:16:06,884 staff training and protocol optimization. 419 00:16:07,424 --> 00:16:09,584 Those are keys. Once you get past that 420 00:16:09,584 --> 00:16:12,784 initial training phase, it's really smooth sailing from 421 00:16:12,784 --> 00:16:13,284 there. 422 00:16:13,985 --> 00:16:16,004 Additionally, I think it's, like, really 423 00:16:16,759 --> 00:16:20,440 important to integrate quantitative plaque analysis directly to 424 00:16:20,440 --> 00:16:22,139 your coronary CTA flows. 425 00:16:22,759 --> 00:16:24,759 So this is the the the the newest 426 00:16:24,759 --> 00:16:27,240 thing that we knew what high risk plaque 427 00:16:27,240 --> 00:16:30,460 look like and what the incremental value of 428 00:16:30,774 --> 00:16:33,815 low attenuation plaque and the non calcified plaque 429 00:16:33,815 --> 00:16:36,615 adds to a coronary CTA. But, historically, we 430 00:16:36,615 --> 00:16:39,174 have not been able to do a a 431 00:16:39,174 --> 00:16:39,995 accurate quantification 432 00:16:40,375 --> 00:16:41,914 for it. So these tools 433 00:16:42,375 --> 00:16:43,674 now allow us to 434 00:16:44,000 --> 00:16:45,940 quantify the plaque. So really, 435 00:16:46,399 --> 00:16:50,159 introducing it, early on and educating your referring 436 00:16:50,159 --> 00:16:52,720 physicians and your your colleagues about, 437 00:16:53,200 --> 00:16:54,960 how we use this plaque data and how 438 00:16:54,960 --> 00:16:57,615 we interpret this data. Allow us to add 439 00:16:57,615 --> 00:17:00,174 this this second level or second tier of 440 00:17:00,174 --> 00:17:02,654 personalized medicine so that it's not one size 441 00:17:02,654 --> 00:17:05,535 fits all. And we already understand so much 442 00:17:05,535 --> 00:17:08,095 now within this short period of time about 443 00:17:08,095 --> 00:17:08,595 how, 444 00:17:09,454 --> 00:17:10,195 there are 445 00:17:11,039 --> 00:17:11,539 significant, 446 00:17:12,640 --> 00:17:14,720 sex differences between between, 447 00:17:15,360 --> 00:17:17,620 risk and plaque burdens between 448 00:17:18,000 --> 00:17:20,660 men and women and how same plaque burdens 449 00:17:20,720 --> 00:17:22,660 can present a very different 450 00:17:23,384 --> 00:17:25,785 profile. It so it allows us to really 451 00:17:25,785 --> 00:17:27,325 get personalized prevention, 452 00:17:28,505 --> 00:17:31,865 across across different gender, different ethnic groups, and 453 00:17:31,865 --> 00:17:34,265 it also allow us to follow-up on therapy. 454 00:17:34,265 --> 00:17:35,724 When we intervene on 455 00:17:36,340 --> 00:17:39,160 therapeutic intervention, we can follow the response 456 00:17:39,460 --> 00:17:41,380 and be able with confidence to tell our 457 00:17:41,380 --> 00:17:43,140 patient whether or not the, 458 00:17:43,619 --> 00:17:46,259 the the treatment is working for them. And 459 00:17:46,259 --> 00:17:48,755 lastly, I would say we have to do, 460 00:17:49,154 --> 00:17:49,654 prioritization 461 00:17:50,034 --> 00:17:52,434 of of workflows. So we have to do 462 00:17:52,434 --> 00:17:53,414 workflow automation, 463 00:17:54,034 --> 00:17:57,095 decision out making algorithm. Again, something like the, 464 00:17:57,474 --> 00:17:59,414 acute chest pain ER protocol, 465 00:17:59,954 --> 00:18:02,960 this allows us to streamline that process. So 466 00:18:02,960 --> 00:18:04,000 it's not a lot of, 467 00:18:04,559 --> 00:18:07,220 hard stops during this process and really, 468 00:18:07,599 --> 00:18:09,539 speed up the adoption for the system. 469 00:18:10,960 --> 00:18:11,460 Fantastic. 470 00:18:12,000 --> 00:18:14,000 Doctor Al Said, I appreciate it. And doctor 471 00:18:14,000 --> 00:18:15,519 Al Azizi, is there anything that you would 472 00:18:15,519 --> 00:18:16,579 add here for considerations? 473 00:18:17,964 --> 00:18:19,424 Yeah. I think raising awareness, 474 00:18:19,724 --> 00:18:21,884 you know, beyond you know, I'm lucky enough 475 00:18:21,884 --> 00:18:24,444 to to have had the chance to to 476 00:18:24,444 --> 00:18:26,845 understand what is CT and work on CT. 477 00:18:26,845 --> 00:18:29,164 And I don't think that it is something 478 00:18:29,164 --> 00:18:31,164 hard to build on and and gain the 479 00:18:31,164 --> 00:18:31,664 knowledge. 480 00:18:32,130 --> 00:18:33,269 And a lot of softwares, 481 00:18:33,570 --> 00:18:35,890 like, clearly, for example, that pretty much gives 482 00:18:35,890 --> 00:18:37,809 you all the information that you need, makes 483 00:18:37,809 --> 00:18:38,869 things very simple. 484 00:18:39,170 --> 00:18:41,490 The message is societies, and there has been 485 00:18:41,490 --> 00:18:43,910 a recent document released by Sky, 486 00:18:44,565 --> 00:18:47,204 which, you know, Sky has been a very 487 00:18:47,204 --> 00:18:49,144 important piece in really pushing, 488 00:18:49,845 --> 00:18:50,644 a lot of these, 489 00:18:51,204 --> 00:18:51,704 discussions, 490 00:18:52,005 --> 00:18:54,744 specifically CT based or CT guided, 491 00:18:55,924 --> 00:18:58,105 deferral and interventions in general 492 00:18:58,679 --> 00:19:00,679 is is an is an important message for 493 00:19:00,679 --> 00:19:01,419 all interventionists 494 00:19:01,799 --> 00:19:04,279 that are kind of, as act as end 495 00:19:04,279 --> 00:19:06,279 users or have always been on the end 496 00:19:06,279 --> 00:19:07,259 user side 497 00:19:07,559 --> 00:19:09,099 of these CT testing, 498 00:19:09,480 --> 00:19:11,899 protocols is to actually engage more, 499 00:19:12,625 --> 00:19:15,825 not specifically in the, you know, taking on 500 00:19:15,825 --> 00:19:18,085 the testing piece, but actually understanding, 501 00:19:18,464 --> 00:19:18,964 learning, 502 00:19:19,424 --> 00:19:21,664 and reacting to it appropriately. Because if you're 503 00:19:21,664 --> 00:19:23,525 given all this data as an interventionist, 504 00:19:24,329 --> 00:19:26,409 it it it probably may make life much 505 00:19:26,409 --> 00:19:28,569 easier. So I think that kind of these 506 00:19:28,569 --> 00:19:29,950 algorithm, these workflows, 507 00:19:30,250 --> 00:19:30,970 that kind of, 508 00:19:31,450 --> 00:19:31,950 discussion 509 00:19:32,329 --> 00:19:34,029 needs to continue to be elevated, 510 00:19:34,650 --> 00:19:37,309 across different platforms being pushed from societies, 511 00:19:38,174 --> 00:19:38,674 especially, 512 00:19:39,054 --> 00:19:42,014 as coronary CTA continues to be really the 513 00:19:42,014 --> 00:19:44,815 the leading test, and becoming a leading test 514 00:19:44,815 --> 00:19:47,615 in in assessing patients either with the prior 515 00:19:47,615 --> 00:19:50,194 coronary artery disease or or basically 516 00:19:50,654 --> 00:19:53,519 a newly diagnosed coronary artery disease and being 517 00:19:53,519 --> 00:19:55,940 used even further to plan interventions 518 00:19:56,480 --> 00:19:58,420 like we do in the structural heart space. 519 00:19:59,279 --> 00:19:59,779 Mhmm. 520 00:20:00,160 --> 00:20:01,779 It sounds like there's so many opportunities 521 00:20:02,080 --> 00:20:04,080 in taking this this kind of approach with 522 00:20:04,080 --> 00:20:06,095 a tech driven platform and also at the 523 00:20:06,095 --> 00:20:08,975 same time, a lot of considerations around investing 524 00:20:08,975 --> 00:20:10,914 in staff training, increasing awareness, 525 00:20:11,855 --> 00:20:14,195 really being grounded in that focus on quality. 526 00:20:14,975 --> 00:20:16,975 Doctor Al Azizi, doctor Al Sayed, this has 527 00:20:16,975 --> 00:20:19,295 been a great conversation today. I just wanna 528 00:20:19,295 --> 00:20:21,819 check-in for a final thought or takeaway. Is 529 00:20:21,819 --> 00:20:23,579 there anything that you'd like our listeners to 530 00:20:23,579 --> 00:20:24,720 know before we close? 531 00:20:25,019 --> 00:20:27,099 Thank you, Erica. It has been great. I 532 00:20:27,099 --> 00:20:29,359 think my final thought will be that cardiology 533 00:20:29,740 --> 00:20:32,539 is continuously evolving, so we're now in an 534 00:20:32,539 --> 00:20:34,095 era of precision prevention 535 00:20:34,575 --> 00:20:36,434 and personalized intervention. 536 00:20:37,134 --> 00:20:38,674 And I think as a community, 537 00:20:39,054 --> 00:20:40,355 similar to what oncology, 538 00:20:40,734 --> 00:20:43,534 when they moved away from tumor size to 539 00:20:43,534 --> 00:20:44,034 molecular 540 00:20:44,335 --> 00:20:44,835 profiling, 541 00:20:45,294 --> 00:20:45,794 cardiology 542 00:20:46,255 --> 00:20:48,115 must move from just stenosis 543 00:20:48,869 --> 00:20:49,609 and qualitative 544 00:20:49,910 --> 00:20:53,349 assessment to more quantitative assessment in the plaque 545 00:20:53,349 --> 00:20:53,849 biology. 546 00:20:54,789 --> 00:20:57,589 Fantastic. Doctor Al Azizi, any final thoughts from 547 00:20:57,589 --> 00:20:58,250 your end? 548 00:20:58,710 --> 00:21:00,710 Yeah. I I think we, you know, as 549 00:21:00,710 --> 00:21:03,105 a field, we continue to evolve, continue to 550 00:21:03,184 --> 00:21:04,644 try to understand the dilemmas 551 00:21:05,025 --> 00:21:07,184 in managing those patients. We will continue to 552 00:21:07,184 --> 00:21:09,505 see younger and younger patients, unfortunately, with a 553 00:21:09,505 --> 00:21:11,984 lot of soft plaque, and the science will 554 00:21:11,984 --> 00:21:14,704 continue to evolve in both directions. One is 555 00:21:14,704 --> 00:21:17,220 the prevention, and perhaps we may go to 556 00:21:17,220 --> 00:21:19,599 a day where calcium scoring is not even 557 00:21:19,740 --> 00:21:22,220 the the initial thought, but actually a CTA 558 00:21:22,220 --> 00:21:24,400 in in assessing patients in an asymptomatic 559 00:21:24,859 --> 00:21:26,940 way, but we need to continue to compile 560 00:21:26,940 --> 00:21:28,619 data to drive us to a level of 561 00:21:28,619 --> 00:21:30,480 evidence that will take us to that guideline. 562 00:21:31,024 --> 00:21:33,744 And secondly, from a therapeutic standpoint, now that 563 00:21:33,744 --> 00:21:35,744 you have coronary artery disease, now that you're 564 00:21:35,744 --> 00:21:37,125 heading to the cath lab, 565 00:21:37,585 --> 00:21:39,744 we are now I think the time has 566 00:21:39,744 --> 00:21:41,284 come to actually use, 567 00:21:41,744 --> 00:21:44,884 tools and tests like this to really prescribe 568 00:21:46,090 --> 00:21:46,590 revascularization 569 00:21:47,130 --> 00:21:49,210 in the cath lab and translate all the 570 00:21:49,210 --> 00:21:51,690 imaging data. And we've seen over and over 571 00:21:51,690 --> 00:21:53,869 softwares and a lot of X-ray vendors 572 00:21:54,250 --> 00:21:56,330 in the cath lab trying to bring that 573 00:21:56,330 --> 00:21:57,390 CT to life 574 00:21:57,690 --> 00:21:59,610 in in the cath labs itself in order 575 00:21:59,610 --> 00:22:00,830 to guide the operators, 576 00:22:01,724 --> 00:22:04,305 to the best possible outcome for their patients. 577 00:22:05,964 --> 00:22:07,884 Well, if I can take anything from this 578 00:22:07,884 --> 00:22:08,384 conversation, 579 00:22:08,845 --> 00:22:10,305 it's that the innovation 580 00:22:10,765 --> 00:22:11,424 at which 581 00:22:11,884 --> 00:22:13,585 I I should say the pace of innovation 582 00:22:13,724 --> 00:22:14,625 in this space, 583 00:22:15,005 --> 00:22:17,970 in cardiology seems to be just as rapid 584 00:22:17,970 --> 00:22:20,609 as the field of cardiology itself is changing, 585 00:22:20,609 --> 00:22:23,329 evolving, and growing. So it it's reassuring to 586 00:22:23,329 --> 00:22:24,769 to hear about all these innovations, and it 587 00:22:24,769 --> 00:22:26,450 would be fascinating to know a year from 588 00:22:26,450 --> 00:22:28,609 now, what some of these diagnostic tests and 589 00:22:28,609 --> 00:22:31,229 pathways would look like. So doctor Al Azizi, 590 00:22:31,229 --> 00:22:32,908 doctor Al Sayed, thank you so much again 591 00:22:32,908 --> 00:22:34,509 for making time for this and for Becker's 592 00:22:34,509 --> 00:22:37,009 today. Thank you, Erica. This was great.