1 00:00:10.565 --> 00:00:13.145 So today we're gonna talk about, uh, SMART CT, 2 00:00:13.145 --> 00:00:14.625 which is a study that Dr. O'Neill 3 00:00:14.625 --> 00:00:16.265 and I we're co-principal investigators on. 4 00:00:16.485 --> 00:00:19.785 So I'm Mike Morris. I'm from Banner Health in Phoenix, 5 00:00:19.815 --> 00:00:22.985 Arizona, and I'm the director of Cardiac Mar and Cardiac ct. 6 00:00:23.685 --> 00:00:25.945 And I'm Wesley O'Neill from, uh, 7 00:00:26.095 --> 00:00:27.825 cone Health in Greensboro, North Carolina, 8 00:00:27.825 --> 00:00:30.465 where I'm the director of Cardiac CT and nuclear cardiology. 9 00:00:30.845 --> 00:00:32.665 And I'm very happy to also discuss the 10 00:00:32.665 --> 00:00:33.865 results of SMART CT with you. 11 00:00:34.285 --> 00:00:37.585 So smart CT showed that using the roadmap analysis 12 00:00:38.215 --> 00:00:41.265 allowed readers to significantly decrease, uh, 13 00:00:41.265 --> 00:00:45.985 coronary CTA interpretation time, uh, independent of, of, 14 00:00:46.125 --> 00:00:47.385 of reader experience. 15 00:00:47.925 --> 00:00:51.865 In addition, we had improved, uh, reader confidence, uh, 16 00:00:51.865 --> 00:00:54.305 but we maintained accuracy, which is really important. 17 00:00:54.895 --> 00:00:57.225 Yeah, and I think, uh, big takeaways for me 18 00:00:57.225 --> 00:01:00.025 for the tool was that, uh, regardless of reader level, 19 00:01:00.025 --> 00:01:03.825 meaning SCCT level two versus level three readers both 20 00:01:03.825 --> 00:01:05.265 showed reductions in read times, 21 00:01:05.265 --> 00:01:07.905 meaning it can make you a more efficient reader regardless 22 00:01:07.965 --> 00:01:08.985 of your level of training. 23 00:01:09.295 --> 00:01:10.665 Another great takeaway was 24 00:01:10.665 --> 00:01:13.985 that level two readers when using the tool actually 25 00:01:13.985 --> 00:01:16.145 performed just as well as level three readers, 26 00:01:16.275 --> 00:01:18.825 which was a really, really key finding of the study 27 00:01:18.825 --> 00:01:19.985 that shows great benefit 28 00:01:19.985 --> 00:01:21.945 regarding the accuracy of using the tool. 29 00:01:22.095 --> 00:01:23.705 Yeah. So let's go through 30 00:01:23.705 --> 00:01:24.745 The data. That sounds great. 31 00:01:25.685 --> 00:01:29.225 We all know that coronary CTA is now the first line 32 00:01:29.355 --> 00:01:32.145 evaluation for patients with chest pain symptoms. 33 00:01:32.615 --> 00:01:36.865 There's an increased demand for coronary CTA as the patients 34 00:01:36.865 --> 00:01:38.385 with chest pain continue to climb. 35 00:01:39.125 --> 00:01:42.025 We all know that coronary CTA interpretation can be 36 00:01:42.025 --> 00:01:43.265 quite time consuming. 37 00:01:43.595 --> 00:01:45.145 There are tools that are needed 38 00:01:45.205 --> 00:01:47.145 to effectively enhance our ability 39 00:01:47.145 --> 00:01:49.105 to read studies accurately and efficiently. 40 00:01:49.765 --> 00:01:53.385 Visual assessment of coronary CTA can be quite challenging. 41 00:01:53.815 --> 00:01:57.225 Data from the substudy of the Scott Hart trial showed 42 00:01:57.225 --> 00:02:00.185 that there was substantial variability in coronary CTA 43 00:02:00.185 --> 00:02:03.265 interpretation even across experienced readers. 44 00:02:03.595 --> 00:02:06.785 There was strong agreement for minimal or mild disease, 45 00:02:07.045 --> 00:02:08.185 but very low agreement 46 00:02:08.245 --> 00:02:10.745 for moderate stenosis in the moderate 47 00:02:10.745 --> 00:02:12.345 agreement for severe disease. 48 00:02:13.365 --> 00:02:15.825 The objectives of Smart CT were 49 00:02:15.825 --> 00:02:17.585 to determine if a commercially available 50 00:02:18.765 --> 00:02:22.545 AI coronary stenosis quantification tool could be used 51 00:02:22.545 --> 00:02:26.545 to reduce coronary CTA times for interpretation, as well as 52 00:02:26.565 --> 00:02:28.945 to maintain reader accuracy and confidence. 53 00:02:29.365 --> 00:02:31.665 We also aim to see if this could reduce inter 54 00:02:31.665 --> 00:02:32.705 reader variability. 55 00:02:33.825 --> 00:02:35.145 A little bit about roadmap 56 00:02:35.205 --> 00:02:38.305 or the automated coronary stenosis quantification tool. 57 00:02:38.815 --> 00:02:40.385 This is an AI based tool. 58 00:02:40.405 --> 00:02:42.465 It has been validated against quantitative 59 00:02:42.465 --> 00:02:43.905 coronary angiography. 60 00:02:44.255 --> 00:02:47.825 It's been shown to be highly accurate in predicting stenosis 61 00:02:48.225 --> 00:02:51.625 severity when compared to QCA data here just show 62 00:02:51.625 --> 00:02:54.105 that the accuracy is very high on a per patient 63 00:02:54.165 --> 00:02:55.625 and per vessel level. 64 00:02:56.805 --> 00:02:58.905 The study designed for smart CT included 65 00:02:59.455 --> 00:03:00.765 three level two readers 66 00:03:00.765 --> 00:03:03.485 and three level three readers from two separate sites, 67 00:03:03.905 --> 00:03:07.085 the readers interpreted 120 coronary CTAs. 68 00:03:07.455 --> 00:03:10.485 60 of these cases were included with the roadmap tool 69 00:03:10.505 --> 00:03:13.845 and 60 were included without each person read studies. 70 00:03:13.865 --> 00:03:16.885 In batch, they read a total of 120 studies, 71 00:03:17.465 --> 00:03:21.245 10 studies per day for 12 days to mirror clinical practice. 72 00:03:21.625 --> 00:03:24.405 It was included that we use this batch analysis 73 00:03:24.425 --> 00:03:27.245 to examine our studies interpretation of one batch 74 00:03:27.245 --> 00:03:30.045 of 10 coronary C CTAs was permitted per day. 75 00:03:30.385 --> 00:03:33.325 The case order and the use of the A-I-C-S-Q were determined 76 00:03:33.325 --> 00:03:36.965 by random assignment to ensure all 120 coronary CTAs were 77 00:03:36.965 --> 00:03:40.005 read both with and without the tool by different readers. 78 00:03:40.425 --> 00:03:43.645 The primary endpoint of the study was average reading time 79 00:03:43.675 --> 00:03:45.045 with and without roadmap. 80 00:03:45.425 --> 00:03:47.845 The secondary endpoints included accuracy, 81 00:03:48.145 --> 00:03:50.125 reader confidence and reproducibility. 82 00:03:50.915 --> 00:03:54.925 This depicts the, uh, figure from the software. 83 00:03:55.505 --> 00:03:57.445 All models are able 84 00:03:57.445 --> 00:04:00.845 to analyze coronary arteries greater than 1.8 millimeters. 85 00:04:01.545 --> 00:04:04.805 The software presents the location and severity of stenosis. 86 00:04:05.385 --> 00:04:07.725 It also shows this in a color coded manner. 87 00:04:08.025 --> 00:04:12.885 Orange denotes mild stenosis, red denotes moderate stenosis, 88 00:04:13.025 --> 00:04:15.325 and purple denotes severe stenosis. 89 00:04:16.025 --> 00:04:19.205 All categories were aligned with CAD RADS 2.0 reporting 90 00:04:19.705 --> 00:04:23.325 and vessel specific curve plan and reformatted images were 91 00:04:23.525 --> 00:04:24.645 provided to the readers. 92 00:04:25.745 --> 00:04:26.765 The primary endpoint 93 00:04:26.765 --> 00:04:30.605 of SMART CT showed a 25% reduction in read time 94 00:04:30.675 --> 00:04:34.765 with the A-I-C-S-Q versus without the interpretation. 95 00:04:34.795 --> 00:04:36.085 Time between level two 96 00:04:36.085 --> 00:04:38.845 and level three readers showed significant decreases 97 00:04:39.085 --> 00:04:40.245 regardless of level of training, 98 00:04:42.755 --> 00:04:45.845 this figure depicts the per patient diagnostic performance 99 00:04:45.845 --> 00:04:48.965 without the roadmap tool for synosis greater than 50%. 100 00:04:49.995 --> 00:04:52.645 Here it has shown that the accuracy was much higher 101 00:04:52.645 --> 00:04:55.125 with level three readers as well as the a UC 102 00:04:55.395 --> 00:04:57.365 with level three readers versus level two 103 00:04:57.365 --> 00:04:58.685 readers, which is expected. 104 00:04:59.825 --> 00:05:02.685 The graph here depicts a per patient diagnostic performance 105 00:05:02.955 --> 00:05:06.005 with the roadmap tool for sun's greater than 50% 106 00:05:06.275 --> 00:05:08.325 between level two and level three readers. 107 00:05:08.905 --> 00:05:11.565 As shown here, the diagnostic performance was quite similar 108 00:05:11.565 --> 00:05:13.685 between both level two and level three readers. 109 00:05:13.955 --> 00:05:15.725 When the A-I-C-S-Q was used, 110 00:05:16.745 --> 00:05:19.845 the slide here depicts the per vessel diagnostic performance 111 00:05:19.845 --> 00:05:23.765 without the A-I-C-S-Q analysis in sun's greater than 50% 112 00:05:24.505 --> 00:05:26.365 and level three versus level two readers. 113 00:05:26.915 --> 00:05:29.605 This shows that level three readers were more accurate in 114 00:05:29.605 --> 00:05:31.765 their interpretations compared with level two readers. 115 00:05:31.775 --> 00:05:35.605 There was a higher sensitivity, a higher accuracy, as well 116 00:05:35.605 --> 00:05:37.965 as a higher negative predictive value in a UC 117 00:05:38.055 --> 00:05:40.165 among level three compared with level two readers. 118 00:05:40.875 --> 00:05:43.685 This figure denotes the per vessel diagnostic performance 119 00:05:43.905 --> 00:05:47.045 of the roadmap tool for stenosis greater than 50% 120 00:05:47.745 --> 00:05:49.725 and level two versus level three readers 121 00:05:49.955 --> 00:05:51.525 with the roadmap analysis. 122 00:05:51.905 --> 00:05:54.325 And this did show that all diagnostic markers 123 00:05:54.385 --> 00:05:56.365 of performance were similar between level two 124 00:05:56.365 --> 00:05:58.480 and level three readers on a per vessel basis. 125 00:05:59.435 --> 00:06:00.965 This figure here shows the cap 126 00:06:00.965 --> 00:06:03.085 and statistic for the intermediate agreement. 127 00:06:03.225 --> 00:06:06.085 And this did show higher agreement when roadmap was used 128 00:06:06.365 --> 00:06:09.525 compared without the agreement actually reached core level 129 00:06:09.525 --> 00:06:12.245 levels, which was seen in the Scott Hart trial when 130 00:06:12.245 --> 00:06:13.485 using the roadmap tool. 131 00:06:14.195 --> 00:06:15.285 This data here shows 132 00:06:15.405 --> 00:06:18.045 that the reader confidence was higher when roadmap was used 133 00:06:18.325 --> 00:06:20.605 compared without, and this was statistically significant. 134 00:06:21.345 --> 00:06:23.805 The conclusions of the Smart CT study showed 135 00:06:23.805 --> 00:06:27.045 that roadmap decreased overall coronary CTA interpretation 136 00:06:27.045 --> 00:06:28.765 time by about 26%. 137 00:06:29.075 --> 00:06:32.125 Similar reductions were observed regardless of reader level. 138 00:06:33.735 --> 00:06:36.125 There was also a benefit in level two readers 139 00:06:36.125 --> 00:06:37.325 to read more accurately 140 00:06:37.325 --> 00:06:40.605 and have improved accuracy when using the roadmap analysis 141 00:06:40.885 --> 00:06:45.085 compared to level three readers roadmap also significantly 142 00:06:45.115 --> 00:06:47.125 reduced inter reader variability while 143 00:06:47.125 --> 00:06:48.325 boosting reader confidence. 144 00:06:48.875 --> 00:06:53.045 Overall, the study results a smart CT demonstrate a unique 145 00:06:53.045 --> 00:06:54.245 role for roadmap 146 00:06:54.245 --> 00:06:56.485 to aid coronary CTA interpretation in 147 00:06:56.485 --> 00:06:57.685 busy clinical practice. 148 00:06:58.515 --> 00:07:01.405 Just a bit about what could be clinically useful to you. 149 00:07:02.015 --> 00:07:03.885 These are data presented from Cone Health, 150 00:07:03.885 --> 00:07:05.205 which is my institution. 151 00:07:05.775 --> 00:07:08.685 We've seen a tremendous growth in coronary CTA over the last 152 00:07:08.685 --> 00:07:10.765 five years, nearly a sevenfold 153 00:07:11.365 --> 00:07:14.965 increase in coronary CTA volume as we have scaled up. 154 00:07:14.965 --> 00:07:16.445 We have needed a way to handle reading 155 00:07:17.025 --> 00:07:20.725 and a dedicated coronary CTA reader has been implemented. 156 00:07:21.575 --> 00:07:24.125 We've also seen a dramatic increase in our 157 00:07:24.495 --> 00:07:26.285 outpatient revascularization rates. 158 00:07:26.425 --> 00:07:28.965 The data here show over the past five years, 159 00:07:28.975 --> 00:07:33.405 we've seen nearly a 25% increase in the rate of elective PCI 160 00:07:33.405 --> 00:07:35.685 and cabbage when implementing the coronary CTA 161 00:07:35.685 --> 00:07:36.965 and FFR CT pathway. 162 00:07:37.825 --> 00:07:39.365 How roadmap could help you as 163 00:07:39.385 --> 00:07:41.445 as it's helped us in our practice in a, 164 00:07:41.445 --> 00:07:44.605 in a busy coronary CTA practice, is it allowed us 165 00:07:44.605 --> 00:07:46.685 to handle the volume more effectively. 166 00:07:47.355 --> 00:07:50.205 This figure just denotes the pathway for a patient 167 00:07:50.305 --> 00:07:53.085 who receives a coronary CTA from referring doc 168 00:07:53.145 --> 00:07:54.245 to implementing this study. 169 00:07:54.945 --> 00:07:56.605 All of our studies are analyzed 170 00:07:56.605 --> 00:07:58.325 with the roadmap analysis upfront. 171 00:07:58.905 --> 00:08:01.405 Our readers are able to effectively triage studies 172 00:08:01.865 --> 00:08:03.965 and send for F-F-R-C-T if needed. 173 00:08:04.295 --> 00:08:07.445 We're also able to effectively identify patients 174 00:08:07.445 --> 00:08:09.365 with minimal or non-obstructive disease 175 00:08:09.425 --> 00:08:11.085 and implement appropriate preventive 176 00:08:11.085 --> 00:08:12.445 therapies in a more timely manner. 177 00:08:13.065 --> 00:08:15.165 I'd like to acknowledge our co-authors on this study, 178 00:08:16.305 --> 00:08:18.685 and thank you for the time and allowing me to present this. 179 00:08:22.615 --> 00:08:26.035 So some of the surprising, uh, results from SMART CT 180 00:08:26.095 --> 00:08:28.395 for me, one of the biggest surprises actually was the 181 00:08:28.675 --> 00:08:30.155 magnitude in reduction in read time 182 00:08:30.725 --> 00:08:33.315 using roadmap compared to not using Roadmap. 183 00:08:33.575 --> 00:08:35.915 If you think about it, that's, that effectively means 184 00:08:35.915 --> 00:08:38.635 that if you're using a roadmap, 185 00:08:38.695 --> 00:08:41.995 you can read four coronary cts in the same time 186 00:08:42.375 --> 00:08:44.475 as it takes someone who's not using Roadmap 187 00:08:44.775 --> 00:08:46.315 to read three cts. 188 00:08:46.695 --> 00:08:48.955 So I think a big surprising thing that I found 189 00:08:48.955 --> 00:08:51.355 with the study was that there was a similar reduction in 190 00:08:51.355 --> 00:08:54.755 read time, uh, for level three and level two readers. 191 00:08:55.115 --> 00:08:57.805 Meaning that regardless your level of training 192 00:08:57.945 --> 00:09:00.885 or where you are, uh, in practice, uh, 193 00:09:01.065 --> 00:09:03.645 you still can see a benefit from roadmap, uh, 194 00:09:03.645 --> 00:09:04.845 with reducing your read times. 195 00:09:04.935 --> 00:09:07.525 It'll make you a more efficient reader, uh, and, 196 00:09:07.585 --> 00:09:09.165 and make you, uh, more effective 197 00:09:09.165 --> 00:09:10.285 at what you do on a daily basis. 198 00:09:10.835 --> 00:09:12.885 Another really surprising result, 199 00:09:13.405 --> 00:09:15.645 although not too unexpected, was 200 00:09:15.645 --> 00:09:18.045 that level two readers were actually able 201 00:09:18.105 --> 00:09:20.805 to improve their reading accuracy to that 202 00:09:20.905 --> 00:09:23.045 of a level three reader, meaning 203 00:09:23.075 --> 00:09:26.205 that the less experienced readers in practice, um, 204 00:09:26.385 --> 00:09:28.525 can really see a benefit here, uh, 205 00:09:28.525 --> 00:09:30.005 to improve their accuracy. 206 00:09:30.225 --> 00:09:32.725 So in a busy coronary CTA practice 207 00:09:32.995 --> 00:09:36.005 with readers from all levels, um, this would be, uh, 208 00:09:36.035 --> 00:09:39.165 very beneficial, um, to those groups, uh, who need 209 00:09:39.165 --> 00:09:40.765 to maintain a high level of accuracy 210 00:09:40.765 --> 00:09:42.125 with less experienced readers. 211 00:09:42.595 --> 00:09:44.325 Yeah, I mean, you know, contextually the way 212 00:09:44.325 --> 00:09:47.165 that I think about it's is effectively democratizes, uh, 213 00:09:47.785 --> 00:09:49.605 the readers so that you can take people 214 00:09:49.625 --> 00:09:51.845 of different strata experience level comfort 215 00:09:51.955 --> 00:09:53.245 with reading coronary ct, 216 00:09:53.245 --> 00:09:55.845 and effectively it elevates everyone to 217 00:09:55.845 --> 00:09:58.085 that same high level of accuracy. 218 00:10:00.905 --> 00:10:05.165 You know, looking at how we can take the results of SMART CT 219 00:10:05.265 --> 00:10:06.845 and implement them in our practice. 220 00:10:07.385 --> 00:10:08.885 You know, we're in an environment 221 00:10:09.335 --> 00:10:13.245 where we see our volumes continuing to increase yearly, 222 00:10:13.705 --> 00:10:16.445 and yet the number of readers that we have interpreting 223 00:10:16.445 --> 00:10:18.165 that CT is not keeping pace 224 00:10:18.165 --> 00:10:19.725 with the overall increase in volume. 225 00:10:20.225 --> 00:10:23.485 And so by using Smart CT 226 00:10:23.545 --> 00:10:26.445 and these results reinforce that we're able 227 00:10:26.445 --> 00:10:29.885 to basically operate more efficiently while maintaining our 228 00:10:29.885 --> 00:10:31.245 same level of accuracy 229 00:10:31.545 --> 00:10:34.245 and quality so we can deal with that increased volume 230 00:10:34.915 --> 00:10:38.965 without having to stay longer, work harder. 231 00:10:39.265 --> 00:10:41.485 You know, we're really reducing that sense of friction, 232 00:10:41.485 --> 00:10:45.285 that sense of mental fatigue by utilizing smart CT 233 00:10:45.285 --> 00:10:47.085 to improve our overall efficiency. 234 00:10:47.715 --> 00:10:51.125 Yeah, I agree. I mean, in in, in our practice for example, 235 00:10:51.145 --> 00:10:54.125 or in any busy coronary CTA practice, uh, 236 00:10:54.125 --> 00:10:55.645 the volume is not going down. 237 00:10:56.185 --> 00:10:57.925 Uh, the number of patients we're seeing 238 00:10:57.925 --> 00:10:59.965 with chest pain symptoms will only continue 239 00:10:59.965 --> 00:11:01.685 to increase spec, especially 240 00:11:01.685 --> 00:11:03.405 with the expected growth in the population. 241 00:11:03.985 --> 00:11:07.045 So we really have to have tools that can allow us 242 00:11:07.065 --> 00:11:10.885 to effectively and efficiently analyze these studies, uh, 243 00:11:11.025 --> 00:11:13.165 as without sacrificing accuracy. 244 00:11:13.545 --> 00:11:15.925 And it, it's really a great tool that's gonna help us do 245 00:11:15.925 --> 00:11:18.245 that, handle the volume that's coming, that continues 246 00:11:18.245 --> 00:11:20.565 to grow with a, with a busy coronary CTA practice. 247 00:11:23.945 --> 00:11:27.245 So I think any, any program that is busy 248 00:11:27.305 --> 00:11:29.485 or has plans to be busy, uh, 249 00:11:29.485 --> 00:11:31.805 regarding their coronary CTA volume should, 250 00:11:31.805 --> 00:11:33.885 should look into a tool like roadmap. 251 00:11:34.555 --> 00:11:36.165 Roadmap should be implemented. 252 00:11:36.515 --> 00:11:38.765 When you start to read your studies upfront, 253 00:11:39.015 --> 00:11:40.845 it'll help you be a more efficient reader. 254 00:11:40.865 --> 00:11:43.805 And clearly the data from Smart CT show that. 255 00:11:44.465 --> 00:11:47.085 So I think any program that's looking for growth 256 00:11:47.305 --> 00:11:49.565 or one in its infancy that has plans 257 00:11:49.625 --> 00:11:52.485 to grow should really look at investing in a tool like 258 00:11:52.485 --> 00:11:55.765 roadmap to make you a more efficient system as well as 259 00:11:55.785 --> 00:11:57.285 to maintain that level of accuracy 260 00:11:57.285 --> 00:11:58.845 as demonstrated through the study results. 261 00:11:59.595 --> 00:12:01.965 Yeah, and you know, for our practice, you know, 262 00:12:01.965 --> 00:12:03.165 on a more granular level, 263 00:12:03.305 --> 00:12:07.005 really integrating roadmap in a way that we're using it, um, 264 00:12:07.665 --> 00:12:10.565 we look at roadmap both before we look at the ct 265 00:12:10.625 --> 00:12:11.845 and then concurrently 266 00:12:11.845 --> 00:12:13.805 with interpretation has really shown us, 267 00:12:14.025 --> 00:12:16.205 or really allowed us to really dramatically improve our 268 00:12:16.205 --> 00:12:18.805 efficiency in terms of interpreting coronary ct. 269 00:12:21.705 --> 00:12:24.755 It's really been a very significant shift in our workflow. 270 00:12:24.755 --> 00:12:26.315 You know, the most important thing in terms 271 00:12:26.315 --> 00:12:29.155 of recognizing the, uh, efficiency benefits 272 00:12:29.535 --> 00:12:34.035 of roadmap is integrating the roadmap analysis into our PAC 273 00:12:34.035 --> 00:12:37.555 system so that the results are sent automatically 274 00:12:37.815 --> 00:12:40.915 and are available to us concurrently with the interpretation 275 00:12:40.915 --> 00:12:41.995 of the coronary ct. 276 00:12:41.995 --> 00:12:44.075 So we don't have to take extra steps of trying 277 00:12:44.075 --> 00:12:45.075 to retrieve the report. 278 00:12:45.255 --> 00:12:48.795 And really by integrating that report into our road, 279 00:12:48.985 --> 00:12:52.275 into our uh, PAC system, we look at the report first, 280 00:12:52.275 --> 00:12:53.355 the roadmap report first, 281 00:12:53.705 --> 00:12:58.035 then concurrently we view both the coronary CT and roadmap. 282 00:12:58.055 --> 00:13:00.515 And by utilizing that methodology, really 283 00:13:01.395 --> 00:13:04.075 maximize the efficiency benefits, um, of, uh, 284 00:13:04.075 --> 00:13:05.435 of the roadmap, uh, program. 285 00:13:06.575 --> 00:13:11.505 We See overall improved reader confidence 286 00:13:11.995 --> 00:13:14.385 using roadmap compared to not using Roadmap. 287 00:13:14.385 --> 00:13:17.345 And so you can extrapolate from that improve confidence, 288 00:13:17.525 --> 00:13:19.825 reduce sense of fatigue, reduce sense of friction. 289 00:13:19.845 --> 00:13:21.185 So overall, uh, 290 00:13:21.285 --> 00:13:24.785 my mental wellbeing is improved when I use Roadmap. 291 00:13:24.785 --> 00:13:27.345 And, and that's just as important in this environment 292 00:13:27.345 --> 00:13:29.145 where we're under a lot of stress, a lot 293 00:13:29.385 --> 00:13:32.185 of demands on our time, and we're really looking for tools 294 00:13:32.255 --> 00:13:34.225 that can, uh, enhance our, 295 00:13:34.525 --> 00:13:36.465 our own efficiency and quality of life. 296 00:13:39.415 --> 00:13:40.715 The impact on patient care 297 00:13:40.775 --> 00:13:44.075 for a tool like roadmap is quality control is making 298 00:13:44.075 --> 00:13:45.275 sure you're not gonna miss anything. 299 00:13:45.295 --> 00:13:46.315 You don't want 300 00:13:46.315 --> 00:13:49.395 to miss a critical stenosis if you're reading your 20th 301 00:13:49.515 --> 00:13:50.835 coronary CTA of the day. 302 00:13:51.555 --> 00:13:54.075 I think that a tool like this can really apply 303 00:13:54.075 --> 00:13:57.075 that proper check and balance, uh, for you as a reader 304 00:13:57.095 --> 00:13:58.355 or for your institution. 305 00:13:58.775 --> 00:14:01.555 Uh, at least that's what we've noticed, um, at Cone Health 306 00:14:04.425 --> 00:14:06.875 Regarding feedback of the imaging team, 307 00:14:06.875 --> 00:14:07.955 whether it's from radiology 308 00:14:08.015 --> 00:14:10.515 or cardiology, has been universally positive. 309 00:14:10.755 --> 00:14:12.235 Everyone is excited to have a tool 310 00:14:12.545 --> 00:14:14.595 that improves their efficiency, 311 00:14:15.175 --> 00:14:16.875 but at the same time, um, 312 00:14:16.905 --> 00:14:19.075 doesn't adversely impact their accuracy. 313 00:14:19.135 --> 00:14:20.395 So this is really what we're looking 314 00:14:20.395 --> 00:14:22.235 for in life is something that makes us faster 315 00:14:22.655 --> 00:14:24.275 and better, uh, more efficient. 316 00:14:24.575 --> 00:14:27.275 Uh, and so there's really uniform enthusiasm 317 00:14:27.375 --> 00:14:30.595 for using this product, especially in our busy practice. 318 00:14:31.095 --> 00:14:33.555 Yes, in our group, which is predominantly cardiologists, 319 00:14:33.605 --> 00:14:36.955 we've been very enthusiastic about the tool really 320 00:14:37.015 --> 00:14:38.835 to help improve our work life balance. 321 00:14:39.215 --> 00:14:41.995 Um, and I think from that piece of it 322 00:14:41.995 --> 00:14:45.035 to make us more efficient, to make us more accurate and, 323 00:14:45.135 --> 00:14:46.675 and really not, uh, 324 00:14:46.785 --> 00:14:49.315 make our jobs more burdensome has really been a positive 325 00:14:49.315 --> 00:14:50.355 outlook for our, our group, 326 00:14:50.355 --> 00:14:52.325 which is predominantly cardiologists who read 327 00:14:55.195 --> 00:14:56.775 our institution at, at Cone Health, 328 00:14:57.075 --> 00:14:58.855 has seen nearly a sevenfold 329 00:14:59.695 --> 00:15:03.015 increase in coronary CTA volume over the past five years. 330 00:15:03.715 --> 00:15:07.575 Um, we're actively looking to expand, um, outpatient sites, 331 00:15:07.685 --> 00:15:10.375 emergency rooms, um, that would be capable 332 00:15:10.515 --> 00:15:14.615 to perform coronary CTA With that growth comes 333 00:15:15.135 --> 00:15:17.255 a physician who must interpret the study. 334 00:15:17.915 --> 00:15:19.695 And I think a roadmap tool 335 00:15:19.695 --> 00:15:23.335 or a tool like roadmap, like, like was shown in Smart CT, 336 00:15:23.395 --> 00:15:25.455 can really, really make you more efficient, 337 00:15:25.525 --> 00:15:27.855 because in our practice, uh, the volume 338 00:15:27.855 --> 00:15:30.255 of coronary CTA is not slowing down 339 00:15:30.715 --> 00:15:32.295 and the demand is only gonna grow. 340 00:15:32.715 --> 00:15:34.895 So I think this is just another, another tool 341 00:15:34.895 --> 00:15:36.695 that's gonna help us be more efficient 342 00:15:36.995 --> 00:15:39.735 as our volume has grown and will continue to grow. 343 00:15:40.525 --> 00:15:43.215 Yeah, and, and for us, this a similar story. 344 00:15:43.955 --> 00:15:47.575 Um, you know, banner is a, uh, banner Health is a large IDN, 345 00:15:47.885 --> 00:15:51.295 both acute care facilities and outpatient facilities, 346 00:15:51.295 --> 00:15:54.415 and we've seen double digit growth year over year, 347 00:15:54.415 --> 00:15:56.815 and we're continuing to see that escalation in growth. 348 00:15:57.195 --> 00:16:00.135 But not only that, in a large IDN we have readers 349 00:16:00.135 --> 00:16:02.575 of varying levels of experience from level three, 350 00:16:02.585 --> 00:16:03.935 level two newer readers, 351 00:16:04.275 --> 00:16:07.655 and that's also another avenue in which we're seeing roadmap 352 00:16:07.655 --> 00:16:11.095 really provide value is democratizing the level 353 00:16:11.095 --> 00:16:12.575 of experience escalating 354 00:16:12.575 --> 00:16:15.175 or elevating that the level, uh, which people are reading, 355 00:16:15.235 --> 00:16:18.655 but also, um, offering that that high level of consistency. 356 00:16:18.675 --> 00:16:21.215 So we're improving accuracy for less experienced readers, 357 00:16:21.395 --> 00:16:24.375 but overall improved consistency across all readers. 358 00:16:24.375 --> 00:16:26.175 And that's another area of real value. 359 00:16:26.595 --> 00:16:28.375 Um, as we continue to see growth, 360 00:16:31.205 --> 00:16:34.385 All patients benefit from the roadmap analysis. 361 00:16:35.185 --> 00:16:37.265 I think any, any coronary CTA 362 00:16:37.265 --> 00:16:39.585 that gets interpreted in our institution goes 363 00:16:39.585 --> 00:16:41.945 through this analysis and we're able to look at it. 364 00:16:42.445 --> 00:16:46.785 So we really don't discriminate against any patient for 365 00:16:47.085 --> 00:16:48.465 who would benefit from roadmap. 366 00:16:48.465 --> 00:16:50.705 We've seen all of them benefit from roadmap if they 367 00:16:50.705 --> 00:16:51.825 get a coronary CTA. 368 00:16:52.255 --> 00:16:55.265 Yeah. And in smart ct, we looked at cohorts of patients 369 00:16:55.265 --> 00:16:57.145 that had less than 50% stenosis. 370 00:16:57.145 --> 00:16:58.265 We looked at cohorts of patients 371 00:16:58.265 --> 00:16:59.585 with greater than 50% stenosis. 372 00:16:59.765 --> 00:17:01.745 And really in all those instances, we saw 373 00:17:02.265 --> 00:17:03.265 reductions in read time. 374 00:17:03.445 --> 00:17:04.705 So all patients, whether 375 00:17:04.705 --> 00:17:07.345 or not you have non-obstructive disease, no disease, 376 00:17:07.925 --> 00:17:11.385 or really severe disease, it's every level of patient, um, 377 00:17:11.405 --> 00:17:14.185 really benefits from that roadmap analysis. 378 00:17:14.685 --> 00:17:17.625 So now that you've seen the smart CT data from Dr. O'Neill, 379 00:17:17.625 --> 00:17:19.785 I'd like to review some cases from our own institution 380 00:17:19.785 --> 00:17:23.025 where we've used roadmap to help us 381 00:17:23.025 --> 00:17:24.865 with coronary CT interpretation. 382 00:17:25.565 --> 00:17:28.265 So, uh, this is a case of a 47-year-old male 383 00:17:28.885 --> 00:17:31.745 who was referred to us because of atypical chest pain. 384 00:17:31.745 --> 00:17:33.385 He's had a history of dyslipidemia 385 00:17:33.805 --> 00:17:37.265 and a family history of premature coronary artery disease. 386 00:17:38.245 --> 00:17:42.505 And I'm gonna use this case to talk about the 387 00:17:43.185 --> 00:17:46.705 paradigm shift that we've, um, encountered now 388 00:17:46.705 --> 00:17:48.145 that we're using Smart ct. 389 00:17:48.145 --> 00:17:53.045 And so this is the, um, old paradigm that I used when, 390 00:17:53.145 --> 00:17:57.325 uh, in interpreting coronary cts without, uh, roadmap. 391 00:17:57.325 --> 00:17:58.965 And so the first thing I would do here, so 392 00:17:58.965 --> 00:18:00.965 what you're seeing here is, is, uh, a screenshot 393 00:18:00.965 --> 00:18:03.525 of basically the two monitors that I use to, um, 394 00:18:03.955 --> 00:18:05.565 interpret coronary ct. 395 00:18:05.985 --> 00:18:07.165 And on the bottom right, you can 396 00:18:07.285 --> 00:18:08.365 see there's the calcium score. 397 00:18:08.365 --> 00:18:10.125 And so when I'm interpreting coronary ct, 398 00:18:10.225 --> 00:18:11.285 at least without roadmap, 399 00:18:11.285 --> 00:18:15.165 the first thing I do is I look at the calcium score. 400 00:18:15.165 --> 00:18:16.645 And in this case, the calcium score, 401 00:18:16.645 --> 00:18:18.245 as you can see, is zero. 402 00:18:18.555 --> 00:18:20.565 Then the next thing I do is the, is the, 403 00:18:20.585 --> 00:18:22.285 is the images set above the axial images. 404 00:18:22.285 --> 00:18:23.845 So I review those axial images, 405 00:18:23.845 --> 00:18:25.845 and you can see those syn a data sets playing. 406 00:18:26.385 --> 00:18:28.925 And I look for, um, as I get an overview to look 407 00:18:28.925 --> 00:18:30.445 for the presence of obstructive disease. 408 00:18:30.825 --> 00:18:34.125 And then on the, on the left monitor there, monitor one, uh, 409 00:18:34.305 --> 00:18:36.085 is the, uh, post-processing software. 410 00:18:36.085 --> 00:18:37.885 So then I pull up the post-processing software 411 00:18:38.225 --> 00:18:40.285 and I go down each vessel to make sure 412 00:18:40.285 --> 00:18:41.845 that there's no occult uh, stenosis. 413 00:18:41.845 --> 00:18:43.725 And so that's the way that I used to 414 00:18:44.635 --> 00:18:46.885 read coronary CTA without roadmap. 415 00:18:47.225 --> 00:18:49.805 But with roadmap, there's really been a paradigm shift. 416 00:18:50.065 --> 00:18:52.165 And first of all, it's important to note that, um, 417 00:18:52.235 --> 00:18:55.365 with roadmap, we get those images sent directly, uh, 418 00:18:55.425 --> 00:18:57.245 to our PACS system. 419 00:18:57.785 --> 00:18:58.845 Um, and so the first thing 420 00:18:58.845 --> 00:19:02.485 that I do is I review the roadmap analysis, 421 00:19:02.485 --> 00:19:05.445 which you can see on, on the monitor two in the, in the, uh, 422 00:19:05.465 --> 00:19:07.085 the bottom, uh, left image. 423 00:19:07.345 --> 00:19:09.925 Uh, then the next thing I do is the cal look at the calcium 424 00:19:10.095 --> 00:19:12.725 score, then that axial dataset. 425 00:19:12.905 --> 00:19:16.685 And then on monitor one, I have the NPRs already sent to me 426 00:19:16.685 --> 00:19:18.965 and I quickly look at the NPRs and clear the case. 427 00:19:18.965 --> 00:19:23.565 So that's really the key, um, differentiator, uh, in terms 428 00:19:23.585 --> 00:19:26.845 of workflow between without roadmap versus with roadmap. 429 00:19:26.845 --> 00:19:29.005 So let's take a a, a bit of a deeper dive in that. 430 00:19:29.025 --> 00:19:30.845 So the first thing, as I mentioned, uh, 431 00:19:30.845 --> 00:19:33.685 is rather than looking at the coronary, uh, calcium score, 432 00:19:33.685 --> 00:19:35.005 which is a, what I used to do, first thing 433 00:19:35.005 --> 00:19:36.085 I do is I look at the roadmap. 434 00:19:36.265 --> 00:19:38.285 And here you can see in this roadmap analysis, 435 00:19:38.285 --> 00:19:40.765 this patient has no coronary disease. 436 00:19:40.765 --> 00:19:42.205 It's clean as a whistle, which is great. 437 00:19:42.555 --> 00:19:43.965 Then we look at the calcium score 438 00:19:43.965 --> 00:19:45.685 and we know the calcium score here is zero. 439 00:19:46.165 --> 00:19:48.765 I look briefly at the NPRs just to confirm 440 00:19:48.765 --> 00:19:50.525 what I'm seeing on the roadmap analysis. 441 00:19:50.865 --> 00:19:52.845 And these are, um, these, uh, 442 00:19:53.085 --> 00:19:54.965 C-A-N-P-R images, nothing here. 443 00:19:55.385 --> 00:19:57.645 And boom, um, I dictate the case 444 00:19:57.665 --> 00:19:59.565 and it, it actually probably takes me longer 445 00:19:59.625 --> 00:20:01.085 to dictate the case than actually 446 00:20:01.085 --> 00:20:02.205 to review the images again. 447 00:20:02.365 --> 00:20:04.365 'cause I already know, based on the roadmap analysis, 448 00:20:04.705 --> 00:20:06.245 I'm looking at the roadmap initially, 449 00:20:06.785 --> 00:20:07.965 uh, before I look at anything else. 450 00:20:07.985 --> 00:20:09.645 And then concurrently with the ct. 451 00:20:09.985 --> 00:20:12.445 And it's really that simplified workflow that allows me 452 00:20:12.445 --> 00:20:16.725 to realize the maximal efficiency gain, uh, with roadmap up. 453 00:20:18.225 --> 00:20:19.845 Uh, so this is a case of a, uh, 454 00:20:19.845 --> 00:20:22.365 56-year-old male who's got a history 455 00:20:22.365 --> 00:20:24.165 of a small bowel adenocarcinoma. 456 00:20:24.555 --> 00:20:25.685 He's on chemotherapy 457 00:20:25.825 --> 00:20:28.725 and had presenting with intermittent, uh, chest pain, 458 00:20:28.725 --> 00:20:30.845 initially started with his first round of chemotherapy, 459 00:20:31.345 --> 00:20:33.845 and then, uh, subsequently was becoming, uh, more frequent. 460 00:20:33.875 --> 00:20:37.005 He's quite an active gentleman, an avid cyclist, um, but 461 00:20:37.005 --> 00:20:39.565 otherwise no real risk factors and was referred to us 462 00:20:39.565 --> 00:20:42.365 because of this, uh, crescendo, uh, chest pain 463 00:20:42.365 --> 00:20:43.445 that he was experiencing. 464 00:20:44.025 --> 00:20:46.885 And so here's the coronary CT on this gentleman. 465 00:20:46.885 --> 00:20:49.205 And again, the first thing is I do is I look at the roadmap 466 00:20:49.485 --> 00:20:52.405 analysis, and you can see already just very easily 467 00:20:52.475 --> 00:20:55.645 that in the mid LAD territory, there's a blue, excuse me, 468 00:20:55.645 --> 00:20:57.965 there's a purple capsule, which denotes a 469 00:20:57.965 --> 00:20:59.405 severe stenosis in that region. 470 00:20:59.705 --> 00:21:02.445 And now if we look at the syne of the, uh, calcium score, 471 00:21:02.535 --> 00:21:05.045 right, the first thing that comes to, uh, mind here is 472 00:21:05.045 --> 00:21:06.445 that the calcium score is zero. 473 00:21:06.665 --> 00:21:08.525 So if I, if this is a case where I first started 474 00:21:08.525 --> 00:21:09.965 by looking at the calcium score, I'd be thinking, 475 00:21:09.965 --> 00:21:11.045 Hey, there's no disease here. 476 00:21:11.045 --> 00:21:14.005 But now with the roadmap, I know there's a severe stenosis, 477 00:21:14.145 --> 00:21:15.885 and yet the calcium score here is zero. 478 00:21:16.145 --> 00:21:18.765 And now the next thing as I do is I look at the NPRs 479 00:21:18.905 --> 00:21:21.085 and on the, on the far left, NPR, that's syn, 480 00:21:21.125 --> 00:21:22.845 A NPR is the LAD. 481 00:21:22.845 --> 00:21:24.805 And you can see in the mid LAD territory, 482 00:21:24.805 --> 00:21:28.765 there's a severe stenosis, um, due to noncalcified plaque, 483 00:21:29.015 --> 00:21:32.685 which corresponds, uh, precisely to the, uh, location 484 00:21:32.685 --> 00:21:34.605 of the stenosis denoted by roadmap. 485 00:21:34.605 --> 00:21:37.045 So here's that curved NPR image on the right 486 00:21:37.145 --> 00:21:39.845 and the roadmap of analysis showing that really tight degree 487 00:21:39.905 --> 00:21:41.245 of agreement between them 488 00:21:41.825 --> 00:21:44.765 and, you know, due to this very severe stenosis, um, 489 00:21:44.825 --> 00:21:46.725 and the patient's, uh, story, he was referred 490 00:21:46.725 --> 00:21:48.085 for coronary angiography. 491 00:21:48.465 --> 00:21:50.165 Uh, and so the top image is the, 492 00:21:50.165 --> 00:21:52.765 is the initial angiogram images demonstrating 493 00:21:52.765 --> 00:21:55.125 that severe stenosis in the mid LAD territory. 494 00:21:55.385 --> 00:21:57.085 And then the bottom is the angiogram 495 00:21:57.095 --> 00:21:59.485 after PCI to showing a very good result. 496 00:21:59.705 --> 00:22:02.365 And the patient's chest pain, uh, went away 497 00:22:02.495 --> 00:22:03.885 after revascularization. 498 00:22:03.985 --> 00:22:06.565 So, um, what is the key from this case? 499 00:22:06.945 --> 00:22:10.845 Uh, you know that using the roadmap analysis really improves 500 00:22:10.845 --> 00:22:14.485 my efficiency by rapidly targeting, uh, those areas 501 00:22:14.745 --> 00:22:17.925 of stenosis that I should be focused on my analysis. 502 00:22:17.985 --> 00:22:21.645 So I can focus my, my energy on the LAD territory. 503 00:22:21.805 --> 00:22:24.605 I don't need to be spending time looking at the CIRC 504 00:22:24.705 --> 00:22:26.125 and the RCA 'cause I know 505 00:22:26.395 --> 00:22:28.605 that there's no significant disease in 506 00:22:28.605 --> 00:22:30.005 those vascular territories. 507 00:22:31.345 --> 00:22:33.725 So this next case is a 70-year-old gentleman 508 00:22:34.025 --> 00:22:36.685 who was referred for coronary CT due to the fact 509 00:22:36.685 --> 00:22:38.685 that he was complaining of dyspnea, exertion, 510 00:22:39.285 --> 00:22:40.885 multiple risk factors, including hypertension, 511 00:22:40.945 --> 00:22:42.365 hyperlipidemia, diabetes. 512 00:22:42.785 --> 00:22:44.525 He actually had an abnormal stress test. 513 00:22:44.785 --> 00:22:47.525 He was gonna be referred for invasive coronary angiography, 514 00:22:47.525 --> 00:22:48.525 but the patient declined 515 00:22:48.525 --> 00:22:50.405 and wanted a non-invasive test initially. 516 00:22:50.665 --> 00:22:53.325 And so that's why he was sent for coronary CTA. 517 00:22:55.185 --> 00:22:57.285 And so in this particular instance, 518 00:22:57.305 --> 00:22:59.485 if we look at first the roadmap analysis, 519 00:22:59.485 --> 00:23:02.005 clearly this is a patient who's got multi-vessel disease, 520 00:23:02.005 --> 00:23:05.285 and you can see that he's got severe stenosis as outlined 521 00:23:05.665 --> 00:23:08.565 by the purple capsules in the RCA 522 00:23:08.665 --> 00:23:10.405 and the circumflex territory, and a 523 00:23:10.405 --> 00:23:13.485 and a moderate stenosis in the LAD territory. 524 00:23:13.505 --> 00:23:16.125 So a patient with multi-vessel coronary disease. 525 00:23:16.125 --> 00:23:19.645 And if you look at the CA images of the, uh, calcium, uh, 526 00:23:19.645 --> 00:23:21.805 score, you can see that the calcium score here 527 00:23:21.805 --> 00:23:23.085 is, is quite high. 528 00:23:23.385 --> 00:23:25.125 And not surprisingly, this calcium score 529 00:23:25.125 --> 00:23:26.205 was in the 1800 range. 530 00:23:26.265 --> 00:23:29.525 So a lot of calcium mentally, again, you're just thinking, 531 00:23:29.525 --> 00:23:31.125 okay, I'm gonna go to battle with this case. 532 00:23:31.545 --> 00:23:33.605 But now with roadmap, it's very quickly 533 00:23:34.165 --> 00:23:36.525 identified those areas that I need to focus in on, 534 00:23:36.525 --> 00:23:38.125 hone in on allowing me 535 00:23:38.225 --> 00:23:41.645 to be more efficient in my ct uh, interpretation. 536 00:23:42.225 --> 00:23:44.765 On the left here, you see the curved NPRs, again, 537 00:23:44.765 --> 00:23:48.965 just showing these areas of a significant disease, um, 538 00:23:49.185 --> 00:23:51.925 in the circumflex and the RCA territory 539 00:23:52.225 --> 00:23:56.165 and moderate stenosis, um, in the LAD uh, territory. 540 00:23:56.225 --> 00:23:59.325 And so this patient was actually referred for FFR ct. 541 00:23:59.745 --> 00:24:02.725 And what's interesting here about the F-F-R-C-T analysis is 542 00:24:02.725 --> 00:24:04.845 now you see the difference between an anatomic test, 543 00:24:05.015 --> 00:24:07.965 which is roadmap, and the, uh, 544 00:24:08.305 --> 00:24:12.005 the heart flow analysis on the F FFR CT analysis on the 545 00:24:12.005 --> 00:24:13.165 left, which is really mimicking 546 00:24:13.165 --> 00:24:14.965 physiology, and we'll go through that. 547 00:24:15.025 --> 00:24:18.565 So the, the box in the yellow is the, uh, circumflex 548 00:24:18.905 --> 00:24:23.085 and, uh, despite the fact that the anatomic test showed 549 00:24:23.085 --> 00:24:25.485 that there was a severe stenosis, uh, due 550 00:24:25.485 --> 00:24:28.125 to calcified plaque in the circumflex, um, 551 00:24:28.265 --> 00:24:31.245 on F-F-R-C-T was non hemodynamically significant. 552 00:24:31.785 --> 00:24:34.685 Um, if we look at the, uh, LAD territory, similarly, 553 00:24:34.685 --> 00:24:38.205 there was a, a moderate stenosis on the anatomic test, uh, 554 00:24:38.345 --> 00:24:41.085 but on, uh, the physiologic test, the F-F-R-C-T, 555 00:24:41.085 --> 00:24:42.685 it's non hemodynamically significant. 556 00:24:42.945 --> 00:24:46.765 And then in the RCA territory, we had a severe stenosis, um, 557 00:24:46.765 --> 00:24:48.085 in the proximal RCA. 558 00:24:48.385 --> 00:24:50.525 And if you look at the F-F-R-C-T results, 559 00:24:50.695 --> 00:24:53.925 borderline hemodynamically significant at 0.78. 560 00:24:54.265 --> 00:24:57.765 And so this patient was referred for, uh, 561 00:24:58.045 --> 00:24:59.805 invasive coronary angiography, 562 00:25:00.025 --> 00:25:02.405 and you see the results of the left heart cath 563 00:25:02.425 --> 00:25:06.005 and the RCA, um, uh, um, on the right. 564 00:25:06.345 --> 00:25:09.005 And what you can see is that, first of all, just as 565 00:25:09.005 --> 00:25:12.685 what we see with the, um, uh, we know about anatomic tests, 566 00:25:12.865 --> 00:25:15.525 the circumflex, uh, does not have a significant stenosis. 567 00:25:15.525 --> 00:25:19.285 So classic overcall due to coronary calcified plaque. 568 00:25:19.705 --> 00:25:22.685 Um, the LAD stenosis, uh, had an FFR 569 00:25:22.685 --> 00:25:24.405 and it was not an invasive FFR 570 00:25:24.405 --> 00:25:26.085 and it was not hemodynamically significant. 571 00:25:26.415 --> 00:25:29.005 Again, just confirming the results of the FFR CT 572 00:25:29.465 --> 00:25:32.765 and the the RCA, uh, stenosis is significant 573 00:25:32.765 --> 00:25:34.485 and actually was significant on FFR, 574 00:25:34.625 --> 00:25:36.085 and that was, uh, stented 575 00:25:36.285 --> 00:25:38.205 and the patient's symptoms, uh, resolved. 576 00:25:38.825 --> 00:25:41.085 So what's the, what are the key learnings from this case? 577 00:25:41.155 --> 00:25:43.205 Well, remember this is an anatomic test, 578 00:25:43.545 --> 00:25:44.605 not a physiologic test. 579 00:25:44.605 --> 00:25:46.045 And we know the difference between an 580 00:25:46.045 --> 00:25:47.725 anatomy and physiology. 581 00:25:47.785 --> 00:25:49.125 And so we're gonna have the sim, 582 00:25:49.125 --> 00:25:50.325 we're gonna have the same sort of limits 583 00:25:50.675 --> 00:25:52.965 regarding specificity, um, 584 00:25:53.145 --> 00:25:56.245 and positive predictive value, uh, when we're using roadmap. 585 00:25:56.265 --> 00:25:58.645 So it can over call stenosis, just like 586 00:25:58.645 --> 00:26:00.525 as readers when we interpret coronary a CT, 587 00:26:00.525 --> 00:26:03.685 we can over call the severity of stenosis, and that's okay. 588 00:26:03.685 --> 00:26:06.325 That's what it's, um, that's a known limitation 589 00:26:06.325 --> 00:26:07.525 for any anatomic test. 590 00:26:07.745 --> 00:26:09.165 But nonetheless, there's still value 591 00:26:09.165 --> 00:26:11.485 because we're still able to quickly focus in 592 00:26:11.485 --> 00:26:14.205 or hone in on those targets for analysis 593 00:26:14.205 --> 00:26:17.445 and really reduces my sense of reader fatigue 594 00:26:17.745 --> 00:26:19.245 as I'm analyzing these studies. 595 00:26:20.345 --> 00:26:24.165 So in summary, with the cases I've shown you just now, uh, 596 00:26:24.165 --> 00:26:26.125 hopefully that I've reinforced the following points. 597 00:26:26.125 --> 00:26:30.045 Number one, um, it's very important to review, uh, 598 00:26:30.045 --> 00:26:32.285 the roadmap analysis, both prior to 599 00:26:32.305 --> 00:26:35.045 and concurrently with your coronary CTA in order to realize, 600 00:26:35.505 --> 00:26:37.805 uh, and maximize the efficiency gains that we get 601 00:26:37.805 --> 00:26:39.045 with the roadmap analysis. 602 00:26:39.345 --> 00:26:41.245 You know, number two is, you know, 603 00:26:41.245 --> 00:26:44.725 using roadmap analysis improves my efficiency, uh, both 604 00:26:44.745 --> 00:26:46.725 for patients who have non-obstructive disease. 605 00:26:46.735 --> 00:26:48.805 Again, because that high negative predictive value 606 00:26:49.065 --> 00:26:51.405 of coronary ct and even for patients 607 00:26:51.405 --> 00:26:53.605 who have obstructive disease, it still is beneficial 608 00:26:53.705 --> 00:26:55.165 by more rapidly allowing me 609 00:26:55.265 --> 00:26:57.925 to focus my attention on those targets 610 00:26:58.055 --> 00:27:01.005 where significance stenosis has been identified by roadmap. 611 00:27:01.225 --> 00:27:04.285 And just as importantly is that reduction in my sense of, 612 00:27:04.305 --> 00:27:07.285 of reader fatigue, that sense of friction that you get, uh, 613 00:27:07.305 --> 00:27:09.925 by, by interpreting some of these more challenging cases. 614 00:27:10.465 --> 00:27:13.205 So I wanna thank you very much for, uh, your time, uh, 615 00:27:13.205 --> 00:27:13.445 today.