Good afternoon everyone. Welcome to today's webinar with GE Healthcare's Cardiology Care Pathway Series. Our topic today is going to be Strategic Benefits of Investing in a Cardiovascular MRI Program in 2025. I'm joined by two speakers. I have Dr. Patel and Dr. Seth Aretsky. Dr. Patel is the Assistant Professor of Medicine, Director of Women's Heart Center and Division of Cardiology at the University of Chicago. And Dr. Seth Aretsky is the Medical Director, Cardiovascular Imaging Director, Imaging Fellowship Program at Atlantic Health System. He's also the Professor of Medicine at Sydney Kimmel Medical College, Thompson Jefferson University. My name is Jamie Warren. I am part of the Care Transformation Team with MedAxiom, and we are excited to have this group with us today. One quick housekeeping item. At the bottom of your screen, you will see a green button to click if you would like to send any questions to our presenters. We encourage you to go ahead and ask any questions as you think of them during the presentation. I'd like to turn it over to Dr. Patel. Thank you. Thank you. Good afternoon and thank you all for joining us today. I am so excited to discuss why a dedicated cardiac MRI should be a key consideration in your clinical practice. Over the next 15 to 20 minutes or so, we'll briefly review the current indications for cardiac MRI and explore its clinical impact. We'll address the operational challenges and the benefit of collaboration with radiology, and we'll conclude with a brief insight into the economics of cardiac MRI and its value in healthcare. Now, as you know, cardiovascular disease is a leading cause of death worldwide. And with this growing burden, early diagnosis and accurate management of heart disease is really critical to reduce mortality and improve quality of life. Now, clinically, our goal is to use the fewest number of tests, testing to get to the correct diagnosis. And this is where we can leverage advanced imaging technologies like cardiac MRI to optimize patient care. Now, as you can see here, cardiac MRI offers a very wide spectrum of applications, which can truly make it a one-stop shop. Cardiac MRI is particularly useful for evaluating the myocardium, heart valves, blood vessels, and pericardium. Cardiac MRI provides unique advantages over other imaging techniques as well, including the ability to assess myocardial tissue characteristics, heart structure and function with high precision, which ultimately guides management and can improve outcomes and decrease other downstream testing. Now, most comprehensive MRI studies can be done in 40 minutes or so, and with newer techniques, which you'll hear about later, even shorter scan times are feasible without compromising image quality and diagnostic value. And some of the techniques that make MRI so valuable, which you'll hear about throughout these talks, include mapping, T1, T2 mapping, which give us quantitative data on tissue composition, such as edema or fibrosis within the myocardium, stress perfusion imaging, which allows us to detect things like ischemia, and late gadolinium enhancement, or LGE, which allows us to detect myocardial fibrosis or scarring. And this has all led to strong guideline recommendations for cardiac MRI in the evaluation and management of coronary disease, heart failure, valvular disease, arrhythmias, myocarditis, and more. And so there's probably every aspect of cardiology that we can now apply cardiac MRI to. And so we'll walk through some of the more common applications with a couple of case examples now. The first is cardiomyopathy. So here we have a 67-year-old male who has a history of atrial fibrillation that was treated with an ablation in the past, who's now coming in with progressively worsening shortness of breath. He's had two prior ablations for recurrent atrial arrhythmias in the past, had initial improvement, but now is having these persistent symptoms of heart failure. His ECG and presentation was relatively unremarkable. And so the question is, well, what now? What can cardiac MRI offer us? Well, it turns out that cardiac MRI can be very helpful with cardiomyopathy. It allows us to see the heart in 3D. We can accurately quantitate volumes. We can look at ejection fractions. We can do flow quantification. And what I want to emphasize is that it can be very helpful in determining etiology and actually probing the intrinsic nature of the muscle and trying to determine the different tissue characteristics. This can all help us ultimately determine prognosis as well. So this patient started off with getting an echocardiogram. His ejection fraction was estimated to be mildly reduced, about 46% or so. There's mild thickening of the left ventricular wall. There's abnormal diastolic function. And the strain images show that perhaps there's maybe some sort of apical sparing pattern, but it's not really entirely compatible with any specific diagnosis. As the echo was overall unrevealing, a coronary CTA was then ordered for workup of his shortness of breath. And again, not revealing, did not show any obstructive coronary disease. The pulmonary veins were also evaluated given his history of ablations and looked fairly unremarkable. Now, ultimately a cardiac MRI was obtained and that showed normal LV ejection fraction, mild left ventricular hypertrophy, biatrial enlargement. Now remember, cardiac MRI is really the gold standard for assessment of volume and function in the heart. In this case, it more accurately quantified his left ventricular function compared to the echo images. The native T1 time and extracellular volume on the bottom left were a bit elevated. Gadolinium kinetics are grossly abnormal. And you can see that there's this diffuse late gadolinium enhancement or the bright white within the heart also involving the atria. And altogether in a pattern suggestive of amyloidosis. The MRI findings ultimately led to diagnosis of AL amyloidosis. And appropriate therapy was able to then be quickly started with improved symptom profile. And of course, this highlights that figuring out etiology is very important. So here's a nice natural history study of cardiomyopathy. And you can see that the prognosis is not the same for all types of cardiomyopathy. And in fact, those patients who have infiltrated cardiomyopathies have significantly poor survival. And so a quick and accurate diagnosis is really needed to help guide management. Next, viability assessment is another common indication for cardiac MRI imaging. And at our site, we frequently get referrals for this indication. So here we have a 64-year-old male who has a history of diabetes, hypertension, peripheral arterial disease. He has known coronary disease, had prior stents placed, coming in with exertional shortness of breath and orthopnea. He had an echocardiogram done, which showed a newly reduced LV systolic function with an LVEF of about 25% to 30% and some wall motion abnormalities. He went on to have an invasive coronary angiogram, which showed obstructive triple vessel disease. And given his comorbidities, his surgical team felt that he'd be at increased risk for a surgical revascularization. And so a cardiac MRI was requested to assess for viability. Now you can see on the left-hand screen that the LV function is severely reduced. There's evidence of thinning and akinesis in several areas, including the basal to mid-inferior inferolateral walls. And so the question here is whether it's worthwhile to take the risks of a procedure to maybe revascularize areas that may already be scarred or non-viable. And so one of the ways that MRI can help us is by assessment of viability with a technique called late gadolinium enhancement. And now, of course, without diving into all the technical details, the delayed enhancement images on the right show transmural LGE, which is all that bright white, and the basal and mid-inferolateral walls, suggesting that that area is unlikely to be viable. There's also another area of subendocardial late gadolinium enhancement in the basal to mid walls, inferior walls, which shows less than 50% involvement of the myocardial wall thickness, suggesting that there's some potential for viable tissue in this region. And how do we know this? Well, it's all based on this really important study, which basically showed that if you have more than 50% of your wall that has hyper-enhancement or scar, there's a very, very low likelihood of recovery of function post-revascularization. Whereas if you have less than 50% of scarred tissue, there's a greater chance of recovery after revascularization. So our patient went on to have bypass surgery, and you can see that his LV function, which was initially severely reduced, improved quite substantially after his surgical bypass. Now, for our last case, cardiac MRI is also feasible and diagnostic in patients who have implantable cardiac devices. Here is a case of a 51-year-old male who has a history of heart failure with reduced ejection fraction, a prior ICD implantation, and an aortic valve replacement who came to the hospital with shortness of breath. His echo had shown severely reduced LV function with an EF of 10% to 15%, previously at 40% to 45%. An invasive coronary angiogram was considered but ultimately deferred in light of profound acute kidney injury, and instead, stress testing was recommended. And so I think this is where there's been significant change in the guidelines that have happened over the past few years when it comes to the assessment of coronary disease. And essentially, any patient who is at intermediate to high risk, it's reasonable to pick any non-invasive stress testing modality that makes sense for that patient. Now, cardiac MRI has multiple advantages, including no radiation, no iodinated contrast, and it can also allow for quantification of myocardial blood flow if you're also interested in evaluating for coronary microvascular disease. A question that comes up is, well, how good is the technique? So here's a large meta-analysis of about 166 articles comparing it to nuclear techniques of PET and SPECT. And you can see here that the diagnostic accuracy is just as good as PET, and again, has that advantage that there's no radiation involved to your patient. And how about long-term prognosis for your patient? Well, that's also been studied. And here's an analysis, an older study of 19 studies with about 11,000 patients who were included. And you can see here that if we tell you that the patient's stress test is normal, that they have a very low risk of cardiac events happening over the next preceding year, less than 1%. Whereas as your stress test becomes abnormal, you can see that that risk markedly increases for the combined endpoints of cardiovascular death and myocardial infarction. So our patient underwent a stress MRI on our 1.5 GE artist scanner. Now, until recently, we were not routinely performing MRI with tissue mapping and stress perfusion in this higher risk population because there were concerns related to safety and perhaps that the metal artifact from the defibrillator could degrade image quality. But you can see here that the LV function is severely reduced. There's thinning and akinesis of the apex, the infraceptal segments. The tissue mapping was diagnostic quality, and it was overall normal. The stress imaging, although you can't really see it quite as well on these images here, the stress imaging did show perfusion defect in the inferior and infraceptal segments. That was present during both the rest and stress, suggesting perhaps an infarct. And the delayed enhancement showed a couple different patterns of LGE, including transmural late gadolinium enhancement in the apex and the mid to inferior and infraceptal segments, as well as subepicardial late gadolinium enhancement in the mid-infralateral segments. And so with these findings, a cardiac catheterization was ultimately performed, and it showed non-obstructive coronary disease. And so with those findings and with the patterns and distribution of late gadolinium enhancement on the cardiac MRI, there was a concern for cardiac sarcoidosis. And so this patient went on to have a cardiac PET, which then supported the MRI diagnosis. A cardiac MRI is frequently indicated for patients who have defibrillators, and we do routinely perform LGE MRIs in this population at our center. And so we published this a couple years ago, looking at current referral indications and how MRI findings influence clinical decision making in this higher risk population. 179 patients were included from our institution, and the most common referral indications were for evaluation of ventricular arrhythmias followed by cardiomyopathy. And the MRI findings impacted clinical management in about 28%, which included medication changes, subsequent invasive procedures, or avoidance of these. And the findings resulted in a new or changed diagnosis in about 36%. And on the bottom right are two illustrative examples. So on the left panel, we have a patient who had a heart failure with a reduced ejection fraction of unknown etiology, who was referred for cardiomyopathy evaluation. The MRI findings then showed LV non-compaction cardiomyopathy. And on the right was a patient with non-ischemic cardiomyopathy and recurrent ventricular tachycardia, who was referred for evaluation of his scar burden prior to ablation. The MRI showed LGE in a pattern that was highly suggestive of cardiac sarcoidosis, which was then confirmed on biopsy. And so our study and many others highlight that the clinical yield from MRI is high, and it provides meaningful information in a significant portion of patients with ICDs. Now, I've only provided a very brief overview of the capabilities of cardiac MRI, but I do hope that one of the key takeaways is clear, and that cardiac MRI really stands as an ultimate diagnostic tool. And at our institution, this recognition I think has been pretty evident. Since the inception of our program, we've seen significant growth in our cardiac MRI volumes. And moreover, with the expansion of protocols to include a broader patient population, such as those with defibrillators and those requiring assessment for microvascular disease and so on, we anticipate that these numbers will continue to rise as we further integrate cardiac MRI within our clinical practice. Now, certainly with growth comes the inevitable challenge of adaptation. Now, cardiac MRI, cardiac imaging rather in general, has experienced significant evolution in recent years. Now, traditionally, the imaging cardiologist was one who specialized in echocardiography, but now the focus has really shifted to multimodality imaging. And this shift is driving substantial structural and cultural changes within both cardiology and radiology groups, impacting both academic and private practice settings. Now, from my experience, having trained with, learned from, and collaborated with a very diverse group of exceptional cardiac imagers across both cardiology and radiology, I believe that this collaboration between these two specialties is essential at every stage of care. This type of partnership not only enhances patient outcomes, but it fosters advancements in education and research and really the field as a whole. However, as one group may eventually assume greater control, challenges can arise in areas such as sharing scanner time and resources, and this can lead to an impact in throughput and care coordination and the scheduling of studies, presenting ongoing obstacles that require ongoing careful management. And this is where a dedicated cardiac MRI can make a significant impact. But of course, what are the associated costs? So here is a high-level overview of the initial investment operational costs, bearing in mind that these can vary significantly depending on factors such as the manufacturer, model, technology used, whether the system is new or refurbished. But I'll give you some general cost estimates for context. So let's start with the cost of a 1.5 Tesla MRI scanner, which is approximately $1.8 million. If we annualize this over a 10-year period, that comes out to about $180,000 per year. Next, for staffing, we'll consider two cardiac MRI technicians with an annual salary of $110,000 each, totaling about $220,000 annually. A service contract typically adds around $100,000 per year, and for dedicated support, such as a scheduler, will account for an additional $60,000 annually. When we add these up, the total annual operational cost is approximately $560,000 per year. Now, it's important to note that these estimates do not include potential cost for installation and infrastructure, such as space requirements, electrical upgrades, or any other construction that's needed to accommodate the scanner size and specialized needs, including magnetic shielding and cooling systems. A common business consideration is that dedicated cardiac scanners, or really any scanners that provide only a single specialized service, such as cardiac studies, may not be fully utilized and won't be able to cover the fixed cost. So let's break down some numbers. In 2023, the final OPPS reimbursement for a routine non-stress cardiac MRI was $368.43. For a stress MRI, this rate increases to about $740, and adding additional sequences, such as phase contrast or MRI imaging, adds on additional reimbursement. Assuming that private insurance reimburses at about three times these rates, a routine non-stress MRI, again, without any of the additional bells and whistles, a routine non-stress MRI would reimburse about $1,100. So assuming your peer mix is like ours, which is about 70% Medicare, 30% private, to cover the annual cost, this amounts to about 1,000 routine, again, non-stress, no additional sequences, MRI studies per year. And that translates to about four outpatient studies per day. Now, if you want to count for inpatient studies, which are not paid a technical fee, make it about five studies per day. With all the indications for cardiac MRI imaging, we at our institution haven't faced any issues with generating enough cardiac studies to fill the scanner schedule during our usual operating hours. And in fact, we typically have a backlog. And I think, you know, this is where some of the newer AI-based techniques for more efficient and rapid CMR, which you'll hear about later, will be very helpful to improve throughput and efficiency. Now, if you're considering starting an MRI program, leveraging existing resources can be very cost-effective. Most modern day MRI scanners are capable of performing cardiac imaging. And so you just need to add dedicated cardiac coils and cardiac-specific imaging software. Your existing PAC system can be used to store and manage images. And currently employed nurses and MRI techs can also cover cardiac MRI, but it would of course need a dedicated cardiac training. Now, I'll conclude by highlighting that cardiac MRI has demonstrated an association with cost savings. In the latest guidelines for acute and stable chest pain, stress MRI has been granted numerous class one indications, reflecting its excellent accuracy in detecting coronary disease. And as a result, many centers across the country are increasingly integrating this technique into the clinical workflows. And so this was a cost minimization analysis that evaluated various strategies for cardiac revascularization across 12 healthcare systems. The study compared a non-invasive cardiac MRI guided approach with two invasive strategies, one with fractional flow reserve or FFR and the other without. And the results showed that the MRI guided strategy consistently delivered moderate to high cost savings when compared to the invasive coronary angiography and FFR strategy across all risk group. And these savings were even greater when compared to coronary angiography alone. And so all these findings underscore the cost effectiveness of using cardiac MRI to guide cardiac revascularization, particularly in diverse healthcare settings worldwide. So to conclude, cardiac MRI is an essential tool to practicing guideline-based cardiology. Cardiac MRI enables more accurate diagnoses leading to the initiation of appropriate treatment and ultimately improving patient outcomes. Early detection and precise diagnosis not only enhances care but also helps reduce overall treatment costs. We didn't really get into this but a fee-for-service reimbursement model requires efficient MRI exams which are certainly feasible and essential. And I think you'll hear a little bit more about those later. And lastly, in a value-based care model, again, the diagnostic accuracy of cardiac MRI plays a critical role in minimizing unnecessary testing and treatments, optimizing both clinical and economic outcomes. With that, I'll thank you for your time. Dr. Patel, thank you for a great presentation. We have two questions from our audience for you. Our first one is, what are you seeing or what do you feel is driving cardiac MRI growth at your facility? And then I would also put just across the United States. Yeah, I think that there's been a lot of changes in recent years with expanding clinical applications for cardiac MRI where MRI really is becoming more mainstream in clinical practice for diagnosing and managing a wide range of cardiac conditions. And I think another key trend is that MRI is really integrated into multimodality imaging teams. In 2025, hospitals, the cardiology programs are really recognizing that a multidisciplinary approach that combines multiple special imaging specialists within cardiology, radiology. And so on really leads to the best patient outcomes. And so because of this collaborative nature, I think it allows for more efficient workflows and really puts imaging sort of at the center of these new integrated care teams. And then the second question we have is, what are you seeing from the latest technology advancements that are being used to support cardiac MRI? Yeah, so I think you'll probably hear about these a little bit more with our second talk, but there are more efficient ways using AI-based platforms to scan and that increases throughput. And so we're able to offer this study to a wider range of patients. The imaging techniques have improved such that breath holding and a lot of the things that were cumbersome for a lot of these scans are no longer necessary for diagnostic images. And so I think with the increases and the advancements in technology to sort of improve image quality and increase efficiency, those have been sort of critical in utilizing MRI, certainly in our practice and I think in others. Thank you, Dr. Patel. Dr. Aretsky, do you have any questions for Dr. Patel? No, I think that was a great talk, Dr. Patel. Okay, well, we will turn it over to you for your presentation, thank you. Absolutely, well, thank you so much for inviting me. I'm gonna talk about the latest advancements supporting cardiac MRI growth. So traditionally, when people have thought of what makes up a cardiovascular department, they really focused on CV surgery, interventional cardiology, heart failure and EP. And imaging was sort of the stepchild. It was never really a focus. There wasn't always a lot of resources put towards it, but really things have changed over the last couple of years, next slide. And the reason for that is, if you notice, CV imaging really feeds and helps all the other subdivisions of cardiology make decisions, including general cardiology. I can't tell you how many times I get a call per week from the electrophysiologist saying, we need to know whether we can put a device in or what type of device and we need to get a cardiac MRI. And this is true, of course, of surgeons and interventionalists who need to know whether there is or there is not viability. And because of that CV imaging has sort of a spoken wheel alignment, the rest of cardiology has become a centered focus. And the reason for this is, as Dr. Patel pointed out, these are just some of the indications for cardiovascular magnetic resonance. And they're very varied and they're very, very broad and they touch most of our patients. So most of our patients that are certainly treated in the hospital or are the sicker outpatients do need a CMR in 2025. And I would say that it's very, very difficult to run a top tier cardiovascular department without advanced imaging, which I believe includes cardiac CT, but certainly includes CMR. And I think what we're finding is that other sites that do not have developed imaging are realizing that they're a little behind. And if they really wanna be a top tier imaging cardiovascular program, they need very good imaging. Why is this so? As Dr. Patel pointed out, CMR is the gold standard for heart size and function. We don't make any geometric assumptions such as echo. We get to characterize tissue. We can do parametric mapping and quantify blood flow, which has become very important. So in the past, CMR has been a somewhat of a lengthy exam and it's been difficult for some patients to, certainly the sicker ones. In our institution, we were doing about 45 minute to an hour examinations. I know many institutions it's longer than that. It was a series of breath holds, some 12 to 20 seconds long, depending on patient's heart rate and the scan you're doing. The whole time patients can't move during the entire examination or we have to start again and they must lie flat. As you can imagine, this is difficult for patients who are claustrophobic, may have back pain, shortness of breath, but there have been significant advances over the last couple of years. The bottom line is, is that thanks to advances that at least GE has given us, Sonic DL, Air Recon DL, free breathing and the soft blanket like COIL, we've been able to make it more comfortable for patients. So I've been doing this for quite a while. And I believe that in the last couple of years, the Sonic DL and the Air Recon DL free breathing has really changed. It's been the most significant change in my practice of cardiovascular MR. And you ask why? Well, we've been able to really, really shorten the examination, make patients more comfortable, deal with patients who cannot hold their breath and claustrophobic patients really enjoy the soft like blanket COIL that rests on their chest. So just look at this. This is a patient that came in July of 2020 and you can see we got really, really nice imaging. Here's a three chamber SSFP. This was a patient who was sent for mitral regurgitation and below it is the matching delayed enhancement image. This patient came back in December of 2024. And I look at this images, look at the contrast, the images on the right, the newer images, they're much crisper, they're clearer, there's a lot less noise in them. This is Sonic DL and it has been a boon to us. Why? Because not only is that image more pretty, it's significantly faster. This image is done in about three to four seconds, whereas the image on the left took us 10 to 15 seconds depending on the patient's heart rate. So faster imaging, cleaner images, less noise. Look at the delayed enhancement image below and you can see that you can even see the mitral valve leaflets in this image. And it's simply because of the advances in Air Recon DL and Sonic DL and it's really changed our practice. So how has it done that? Well, we have improved patient comfort. If you have improved patient comfort, you're gonna get improved images. The patients are more comfortable and they're gonna be able to follow the instructions better. Increased patient throughput. Now this is extremely important in our practice. We have been able to increase the number of studies without increasing scanner time. In our institution, we increase every year somewhere between 10 and 20% in terms of our CMR growth. That is significant. And you have to realize, where am I putting these patients? Well, thanks to Sonic DL and the work that GE has done to speed up the imaging, we've been able to actually take a block of patients where let's say we used to do six or seven patients and now we can do nine or 10 patients. So we've been able to increase the number of patients we've done without adding any cost to the system. In fact, you might say that the scanner in the same time is making significantly more revenue than it used to. In addition, we have more choices with patients with arrhythmia. We now have free breathing or one RR acquisition, which also has allowed us to image patients who cannot hold their breath. So the bottom line is increased financial return on scanner time, increased patient comfort, and you're able to scan high quality images in more patients than you used to be able to. Well, what does this lead to? This will lead to improved patient satisfaction. Patients come now, they get their MRI. Imagine that guy came in 2020, took let's say 50 minutes to an hour. He comes now and it takes 30 minutes. He's like, wow, that was great. Improved physician satisfaction. Why? Well, we get our patients in quicker. We can do more patients. Physicians get their studies done quicker, right? Due to the increased speed of diagnostic and prognostic evaluation. Improved in and out for inpatients. You know, CMR is mostly an outpatient imaging modality, but of course, as you know, we do have to do inpatients. Due to the speed of how we're able to do outpatients, we're now able to stick our inpatients in between and get them through quicker and cycle them through. And this has improved our financial health. Not only do we get the patients in and out of the hospital more, we're able to do more patients in less time. So what's CMR 2025 and beyond? Well, I think we're only gonna see an increased demand for many reasons that Dr. Patel showed you. And again, at our institution, we're seeing the demand just increase. Also, we don't wanna hold up the workup of patients, the diagnosis of patients. Certainly, you don't want to be responsible for holding up the discharge of patients. In addition, I think it's important. If you invest the time and the energy and the financial resources to build a CMR, you can actually do your imaging for other institutions. At my institution in New Jersey, we do the CMR for other institutions that just don't have a program. We get their referrals. So not only are you able to image your own patients, you're also able to image patients from other institutions that have not put the time in to setting up a CMR program. Thank you very much. Thank you for your presentation. We also have a couple of questions for you from the audience. The first one, I'm hoping that I tee this up correctly, but from a physician's point of view that is going to be going and meeting with their C-suite to start to add or even scale cardiac MRI, is there any suggestions or information that you would say to be prepared with to come to for that meeting? So, you know, there's two aspects to that. There's the financial aspect where you have to build a business plan. But I think I tried to, in the beginning of my talk, lay out the fact that if the hospital or your institution, and I think this is a really important point to make, wants to be considered a top tier cardiovascular program. You cannot do it in 2025 without an investment in imaging. It's just not gonna happen. And someone else will steal your lunch. Someone else will realize that in this area, there's no CMR program and they will start imaging your patients. So not only do you wanna make a business plan, like Dr. Patel pointed out so well, of how many patients you're gonna get, right? And you can say, well, we might start slowly, but we'll eventually grow. I think you have to realize that for the overall health of your cardiovascular department, right, what do you consider? Do you consider it just a small kind of program or you consider it a robust program? And in addition, do you want other people doing the imaging for you? So it's not simply just a business plan. You have to think of it holistically, how it affects the outlook of your whole program and how people view your cardiovascular program. That's great. Now, from a clinical perspective, the question that we had is this, can you provide us an example where cardiac MR changed the outcome for a patient? Well, absolutely, it changes it in our institution every single day. Patient says, oh, you know, sent for, let's say mitral regurgitation. I think the patient has severe MR, I'm gonna do surgery. Well, CMR is a more accurate tool to do it. Guess what? Patient doesn't have severe MR. We can let them slide for a couple of years and follow them up. Or the EP guys are deciding whether we should put an ICD or we should put in a regular device. It's often based on what we find in a patient's with ventricular tachycardia or suppose it's sarcoid. Should we revascularize the patient? Well, is the tissue viable or not? Is the anterior wall alive or dead? And the MRI gives you that answer. So this is happening every single day in institutions which have very high level CMR programs. Great. And then same similar question that Dr. Patel got is, what are you seeing with the latest technology advancements to support cardiac MR? So we're GE users. And I'm gonna be honest with you, GE the last couple of years has really, really turned it on. We have gotten so much great technology, so much wonderful things from them. Again, we've been able to increase the number of patients we've done without really buying any new scanners. In addition, I will tell you the one thing they did for us is you don't even have to buy a new magnet. They've built new scanners around our old magnets. That saved us millions and millions of dollars in construction costs. And it was allowed us to upgrade a whole fleet of magnets that were already there to cardiac ready scanners. So those two things have been very helpful to us. Great. Dr. Patel, if you'd like to come back, do you have any questions for Dr. Etzke? No, that was fantastic. Such a great overview of everything that modern day cardiac MRI can offer. And then Dr. Patel, do you have any experience with the Sonic DL? So we are probably the latest to get on board with the Sonic DL. I do have experience with it, and I think I found it to be particularly useful in our patients with arrhythmias and our patients who have defibrillators who really don't want to keep their therapies off for long. But the image quality has been phenomenal, and the throughput really has been excellent. And I think that has led to a huge argument within our institution to adopt that technology. So for both of our speakers, I have a question for you. So what is one myth or an outdated perception about cardiac MRI that you'd like to debunk? Well, there's a couple of myths, but one of it is that it's so expensive. It's actually not that expensive. The Medicare reimbursement for a cardiac MRI with contrast is in the order of $400 to $500. It's way less than a nuclear stress. It's not that much more than a stress echo. People think it's a very, very expensive test. It, in fact, is not an expensive test. What is, as Dr. Patel pointed out, it's a very powerful test in getting the most accurate diagnosis for your patients. Dr. Patel, would you like to add anything? Yeah, I think something that comes up commonly as well, these tests are so long and the bulk of the information comes at the end when you do your gadolinium enhancement imaging and such, and patients just get so tired and the image quality is terrible. But I think with all of Dr. Jarecki's examples, you can see that these scans can be done in such a truncated amount of time. And with these newer platforms, the image quality is certainly not compromised. If anything, it's improved. And so that these scans, which were traditionally so long and cumbersome, it's just not the case anymore that we could do these in a shorter amount of time. We can pick and choose which sequences are needed, but because we're able to do these in a shorter, more rapid profile, that the image quality and the patient's experience is quite positive. Right. So for many of the programs, we see that they start kind of in a shared service model with radiology. So do you have any tips for physicians with having that relationship with adding cardiac MRI to the radiology camera? So at our institution, cardiovascular imaging resides in cardiology, but we do share equipment and actually we use that to our advantage. We're our own department and radiology is a very big department and we actually game plan together. What do we need? It's much easier when two large departments go to a hospital administration and say, we need this scanner, we need this equipment. It's much harder for them to turn you down if you have that sort of power behind you. So although we control the actual imaging, we do work in concert with our radiology department to decide strategically what equipment and where to put the equipment. I have found that working with radiology is actually super beneficial. They bring a lot of things to the table that cardiology does not, and we bring a lot of things to the table that they do not. So I think trying to make peace and trying to have a good relationship is very important. Dr. Patel? Yeah, we have a slightly different model in that our imaging falls under radiology purview and that certainly can have its challenges and such, but we actually have a very collaborative relationship with our radiologists and that is absolutely critical. I think radiology obviously brings their technical expertise and so on, but they also recognize the value that cardiology brings. And I think undeniably, cardiology increases sort of the referrals for a lot of these scans, right? I mean, if you look at sort of where most of our studies are or how most of our referrals are coming through, it's from cardiology, it's coming from other neighboring community hospitals or other practice settings, cardiologists that are referring their patients over. And so I think we're generating most of the cases and such, and so that collaboration is critical. And I think both groups in our institution recognize it. Our training program is also conjoined and so there's no difference as a trainee and a day when you might read with a radiologist, a day you might read with a cardiologist. And so I think all these things have led to a really collaborative environment. So what are your recommendations when a site is thinking about having a dedicated program? At what point should they be thinking about that? Well, I think everyone should think about it. If you're a big enough institution and you have these cardiology patients, you should be thinking about having advanced imaging, not just cardiac MR. I mean, I think you should have cardiac CT. I think people should be doing cardiac PET. I mean, they should be doing all of these things for their patients. I just don't know how you can thoroughly treat your patients in 2025 without these imaging modalities. So in my perspective, everyone who has a big enough institution, obviously if you're a very, very small hospital and there's limited equipment, but often even small hospitals are attached somewhat to larger hospitals in this day and age that should be encouraged to do it. You wanna make sure when you start your program, you're gonna have enough patients to do it. But remember, it's always best to start slow and go low. I mean, start slow and have lower expectations. You tend to be less disappointed, but you'll be surprised how fast you'll grow. I think what I would focus on is doing quality imaging. If you're gonna start a program, you need quality imagers who are really dedicated to the craft, not someone who's in the office most of the day and is letting the tech scan away while they're in the office. No, you need someone who's really hands-on, who's at the scanner, who's dedicated. If you're not gonna do quality work, it's not gonna work out. But if you find a physician, cardiologist, radiologist, who's dedicated, well-trained, dedicated to do quality work, dedicated to be involved in our institution, we always have a cardiologist at the magnet or at the disposal of the techs. That's what their focus is that day. If it's their day, that's what they're doing. And not only that, it helps us get faster because we can say, okay, this is what the indication is, just scan this and let's get the patient out. And we watch the images as they come off the scanner, and that allows us to speed through the patients as well and get high quality images. Yeah, I would echo all of that. I think that the shift is now on sort of multimodality imaging centers in this day and age. And so access to all sorts of imaging modalities is sort of critical. And I think, as Dr. Gretzky mentioned, there's sort of a distinction between now, between a general cardiologist versus an imaging cardiologist. And so that really does allow for time at the scanner, at our institution as well, when we're on an imaging service, that is all we're doing all day, every day, right? And I think that has also allowed us to grow into outpatient, into some of our referral locations or offsite locations where we're now expanding to have MRI programs at these other locations, just because our volumes are growing and we have the dedicated expertise to sort of serve all of that. I'm gonna read a question from our audience and I'm not sure I have all the pieces, so we'll figure this one out together. But they said, place of MR versus PET, viability with FDG, and if you have PET MR, would you invest in it? So we have both at our institution, we have a cardiac PET program and a cardiac MR program. I will tell you that most of our viability is CMR and I don't, Dr. Patel can tell us what she's doing in our institution. And the reason is, I think, so CMR has a few advantages over PET and one disadvantage. The advantage is when you do a CMR, you get a lot of other things, not just viability. You get structure and function of the heart, you get assessment of the valves, the pericardium and the viability. And you could do a stress test at the same time if you want. You can do all of that in one sitting with one dose of gadolinium. For a PET viability, that's what you get. You only get viability. Also, depending on if your patient is diabetic, what their sugar status is, it can be painful because you have to give insulin, maybe you wanna give, you know, you have to give insulin to your patient, you have to play with the sugars before you can give the FDG. And it can be very, very labor intensive. So I think for that reason, the large amount of the big, large majority of our patients get viability study by CMR. Another reason is CMR is you can look at what's viable and what's not viable. For FDG PET, you're really just seeing what's missing. I guess in a sense you are seeing what's viable, what's not viable. In CMR, you see the scar. So we tend to do most of our viability by CMR. I don't know what Dr. Patel's experience is. Yeah, ours is similar. I'd say the majority of our viability studies are certainly referred for cardiac MRI. For all the reasons that you mentioned, it's just, it's sort of a one-stop shop. But I think also, you know, when assessing for viability, those scans times are pretty short. You know, if you have sort of a targeted indication, we can, you know, we can get through quite a few of these. There's also no radiation. And so, you know, for folks who need repeated studies or so on, it's kind of a nice modality to have a baseline and be able to know that you, you know, we can rescan and such at later dates without that added radiation and so on. And so for us, it's very similar in that, you know, I think our, we have a lot of expertise in MRI. And I think that there's a lot of buy-in from our other subspecialists and the institution with the MRI data. So as we're down to the last few minutes, I always like to ask this last question, especially when we have experts in the room who have successful programs. From a physician point of view, what is your best advice or tip that you would provide to another physician that is thinking about bringing cardiac MRI to their program? So I make it high quality. If you do it, do it right. Make sure that you're training the techs correctly. If you're gonna get, in other words, if you're gonna convince your administrator for the financial backing of a program, let's say you've done all that, make it count. If you do high quality work, I have found all you need to do is help a cardiologist one time take care of their patients and then yours forever. They'll come back to you for answers. So if you do high quality work, you'll be able to give people very good answers, help them take care of their patients. That's all they care about. And that's what I would focus on. Yeah, absolutely. I think buy-in is essential, of course. It goes without saying. So for every MRI, we're expanding. And so for every MRI that's done, I'll call the ordering physician and review images with them. And I think then they start to understand the importance and the value of MRI. And it's palpable and everyone sort of buys into that. And I think the numbers sort of speak for themselves, but if you can really show people, hey, you're ordering this study, here's what we can tell you, here's what I can show you, that buy-in really is palpable and sort of immediate. Well, I just wanna send a very special thank you to both of our speakers for being with us today, your time and expertise and for sharing. A special thank you to GE for having this presentation for Cardiac MRI. For our viewers, this is recorded and will be available for replay. And we just wanna send a very special thank you to those attending. Everyone have a great afternoon.

Cardiovascular MRI

Cardiac MRI

Diagnostic capabilities

Technological advancements

Patient management

Collaboration

Economic viability

Quality imaging