Everybody, thank you for joining today's webinar. We are going to pause just a minute or two before we kick off today, as we wait for more to join us. And we see them coming in now. So we're gonna wait another minute or two to allow time for more folks to come in before we start. So thank you for your patience. Okay. It looks like we've stabilized a little bit on our attendees. I see a few more joining. So we will kick off and get the webinar started for those of you that were on time. So thank you so much. My name is Joe Sasson. I'm the executive vice president of MedAxium. I'm responsible for our industry relations arm. So therefore I have the honor and the pleasure of bringing you today a wonderful webinar put on by Oshie Hart and Vascular in the Jacksonville, Florida area in collaboration with GE Healthcare and MedAxium. And today's webinar is going to be titled Utilizing Novel Digital PET-CT Technology to Elevate Cardiac Patient Care. Now throughout today's webinar, you will be able to communicate with us through the Q and A feature. So at the bottom of your screen, there'll be a button that says Q and A, and from there you can ask questions. Feel free to ask them throughout the webinar, but during today's webinar, chances are we're going to hold those questions until the end. But if we do see something that is, you know, warrants stopping the webinar, we will do so and ask that question midstream. Otherwise expect your questions to be answered by the end of the webinar. Now in the chat function, you will get a link to download today's slides. So you'll see that come through and it may come through throughout the session today where we may repost those. The chat is not a place to typically chat. It's just to grab the webinar slides. Any communication will be done directly to the panelists or the presenters or the hosts of the meeting on the logistics side by doing the Q and A button specifically. So I'd love to introduce today's presenters. We have Dr. Ashi, and Dr. Ashi is a world renowned and trusted expert in heart and vascular disease. He is an interventional cardiologist and he works with referring patients, referring physicians and his patients for consultative cardiology, interventional cardiology, endovascular medicine, and vascular medicine. He is also the president and the medical director of the vascular medicine and vein clinic. Along with him as well is Dr. Mohanad Bisharat, and Dr. Bisharat is an experienced interventional cardiologist, endovascular specialist as well. And he's passionate about helping sick patients with cardiac and vascular diseases to get better by exploring simple and complex therapeutic options, especially including newer technologies that are available. So we are thrilled to have those with us today. And I would love to turn over today's presentation to get started to our presenters. And so thank you so much for being here and sharing all of your intelligence with us today. Please take it over. Hi, good afternoon, everyone. My name is Majdi Ashi. I'm a cardiologist at Ashi Heart and Vascular Center. And here we're collaboration with GE Healthcare System and MedAxiom. We're presenting to you about the newest, latest, greatest PET scan, CAT scan, basically technology and hopefully that will elevate cardiac patient care. Again, who's Ashi Heart and Vascular? I'm an interventional cardiologist, vascular medicine, endovascular. I've been in the area for 26 years, but Ashi Heart and Vascular, we started this center in 2015. So we've been here eight years. We've been serving the northeast Florida as well as South Georgia. We have about 12 offices. It encompasses basically our outpatient cath lab. We used to have a PET scan, CAT scan in the past, but now we've upgraded it to the OmniLegend. We have vascular labs, echo labs. We have 10 physicians, six nurse practitioners, and we have pretty much every subspecialty of cardiology covered from vascular, endovascular. We have non-invasive, we have structural, and we have electrophysiologists, and we have a lipid clinic, DVT clinic, et cetera. So basically we're encompassing all these under one roof. And that's why we also wanted to upgrade our technology to bring the PET scan, CAT scan, 128-slice CT with AI technology. We tried to be on the cutting edge. We've been, at least in this community, we've been the first in a lot of the first procedures. And we were the first to open an OBI lab. And I've been reading PET scans for about 26 years. You know, the hospital had PET scan scanners, and we decided, you know, to open our own PET scan center. And we did that about six years ago, and we just upgraded it this year based on this new technology. And also we have structural now, we want the CAT scan portion to be part of it. We want to see CAT scans and we want to see the PET scans. So we have this ability to work with patients under one roof, which is cost-effective and same time under our control, and we can see everything ourselves. As for the technology, I'm going to let Dr. Bisharat talk about the PET scan images and why we chose this technology. Thank you. It's a pleasure to be part of this podcast. I believe it's all about delivering the most accurate, the safest technology to our patients. Being able to incorporate the future technology into the day practice is a key word in delivering best care to our patients. I think being able to deliver all these technologies to do all inclusive testing and having the most accurate results that cardiology or science can provide to patients is a key element in empowering the patient and the physician and the providers to be able to give their patient the best advice and to deliver the best care. I think based on this legacy of 26 years of building a top-notch practice and being able to deliver the best care that puts our practice and our providers into the level of being consulted as second and sometimes third opinion, and to be able to empower my decision in making a clinical plan of care for my patients, we decided to proceed with the best technology available in the market nowadays. PET scan, as good as science can give you, delivers something in the range of 97% accuracy rates. I think that's a very important key element in our decision in incorporating this technology. Very few centers practice on the PET scan nowadays, but we're hoping that our experience sets the path for many other institutions around the country and maybe around the globe to adapt the most accurate testing results available. When it comes to PETMAGY, I think we've been using this technology for quite some time now. I believe we have achieved a very, very good accuracy result in not only performing them with our team of technologists and support, but also by being able to build a plan of care for our patients that delivers their best care. Using this technology for PET, for instance, and I think that's on a personal level, has cut down the number of false alarms or false results that come from the older generation of technology. If you remember those days when stress test results were in the 80s, 80% accuracy rates in terms of fidelity of the results. Nowadays, I can empower my decision and I can take my patients into a 98% accuracy rate of those decisions. That's paramount. That's great for patients and that will deliver not only confidence in my treatment plan, but also a lot of other decisions are based on these results. Their eligibility for surgical interventions, their eligibility for operating with heavy machinery, a lot of things depend on results on stress testing. Now to make this even more exciting, our new technology that GE has provided has also one of the most accurate CT scans that we have with 128 slice. I am able to give my patient and provide the plan of care, the best results that can come from reading those CT scans, whether it's for the brain, for the vascular structures of the neck, the carotids, whether it's the heart, the aorta, the lower extremities, all can be done under one ceiling. You can see this beautiful machine behind us. It just gives you all the results that you look for at once in a very accurate and high fidelity system. We are just thrilled to be able to enjoy this technology and provide this to our patients. I think Dr. Bishra, you summarized basically why we brought this new technology despite the expense of it, but it's worth it in a sense of giving accurate testing results, also being able to do patients with very high BMI, big chested men. It's cost effective. Even insurance companies are pushing for it because they know for a more accurate result, they're going to have less invasive procedure, which is very costly at the hospital. People ask me, which patients do you choose for a stress test versus a PET scan? Of course, BMI has something to do with it. Accuracy has to do with it. If we have a patient who's had already multiple interventions, the patient had CABG, they're complicated. I don't want one of these tests that's going to give me 50-50 or 70% or 80% accuracy. I'd like to have something more accurate. Also, the CAT scan images, when we do the CAT scan, sometimes we actually have discovered incidental finding like a lung nodule or other abnormalities that were not there with a regular stress test. We can see more clearly the calcification on the coronaries that we didn't see before. The new system, it's a bigger circumference. Patients are more comfortable than the older system that we have. Also, it requires less malicuries than the older system that we had, especially even with a large size people, we're requiring less malicuries. Hopefully, it'll save us some more malicuries for the generator. I think that's very important. Everybody probably still remember those days when a stress test was a couple of hours and sometimes maybe two-day steps where a patient has to come and do one portion or one half of the test in one day and do it the other day. With this technology, with PIT technology, which is the most accurate, not only accurate, it's the fastest, the speedest. A patient comes in and the scan starts in 30 seconds after they get the stress dose. There is no lay time, there is no drag time, there is no exposure. The tubes are getting better and better. They are bigger, more roomier. We stopped seeing those patients who are claustrophobic because the tube is just as open as it can be. We have actually took this to the next level by being able to scan more patients in the same amount of time. That is not only safety, but it's also efficacy. Patients now can resume their daily activity after the stress test is over because the whole thing can be done within 30 minutes. Given the fact that this could have happened over 48 hours time, that's a tremendous gain. That's good for patients. You shed some light on the insurance policies. In healthcare dynamics and from the monetary part, anything that would cut down the number of false positive tests and provide better accuracy in determining which patient population would require more invasive testing, where it might require hospital stay or more complicated interventions, being able to control this through a very selective gatekeeper is a key element. A lot of these strategies are based on how each practice and each area is processing their stress tests. I think by introducing a PET scan to any system, this will improve their accuracy. They will cut down their false negative and false positive rates in their testing. That's tremendous. That definitely would put you into the preferred list of any insurance policy with those kinds of results and service line. Another thing with this, we can do viability studies. A lot of surgeons before they operate or before we do go after CTOs, chronic total occlusions, when we have a viability study, you can do a viability study to see if it's viable. We're not going to intervene on a patient that has a dead muscle. The other thing that we can do in this machine now, we can do actually sarcoidosis, cardiac sarcoidosis. As far as I know, the only place that's doing cardiac sarcoidosis now is at Mayo Clinic. We'll be the only center in this town that's able to do that. Of course, at probably a lower cost because we're not a hospital facility. I'm going to turn into our technologist. She's a CAT scan and a PET scan nuclear technologist that's been with us for about 15 years. Ashley Bird has been under our umbrella for the last 15 years working hard putting this together. She started doing the PET scans with us and now she's doing the new technology, the CAT scan. What I'm going to ask Ashley to talk about, how is the PET scan? From the time we order it, can you just go through step-by-step really quick of what do you do exactly with the patient just to show the audience? Can you guys hear me? We're good? Basically, how it works is the patient sees the doctor, the test is ordered. Once the patient arrives at the clinic, we bring them back, we explain the procedure to the patient, do some consents, make sure they understand what they're here for. At that point, we put an IV in and once the IV is in place, we bring them into the scan room. All of that usually takes about 5 to 10 minutes. It's very short. Once the patient's in the room and on the table and hooked up to everything that's necessary for the scan, the scan itself is pretty quick. It's about 20 minutes total. We do a quick CAT scan for positioning and then the PET pictures take about seven minutes each. In total, table time is about 20 minutes or so. Like Dr. Ashi was saying and Dr. Bichirot was saying, it's very convenient for the patient because it's a really quick scan for them. A lot of the times, they dread coming in for their stress test because they're used to the old way and they think they're going to be here for a few hours and it's going to be up and off the camera. But with this, it's just in the camera, one shot, and out in 20 minutes. Usually, the patients will say how easy it is and that they shouldn't have dreaded their test. They also mentioned that we are now giving less dose based on the sensitivity of the new scanner, which is really nice. Used to with the old one, if it was a heavier patient, over 200, 250 pounds, we'd have to give up to 60 millicuries sometimes per dose for the rest and the stress. And with the new one, we're maxing out around 20 to 25 millicuries, you know, per rest and stress image. So it's a significant difference, which is great for the patient. And we can save the generator and we can do a couple of more patients. And of course, Dr. Ashi wants to save money on the generator. So I think we have a question. I think you have a question. Can you talk a little bit about the workflow capabilities because of OmniLegend, that it has to help facilitate working higher volume patients? Yeah, so one of the biggest differences as well is the processing software. A lot of it is automated with the new system. So with the older system, we would have to do a lot on the backend once the patient was finished or during the scan itself to process the images. But with the new scanner, it does a lot of things automatically on its own, and it has significantly dropped what we have to do on the backend. So therefore, we can just get the patients in and out and get the images that we need and move on to the next patient. So we're able to do quite a few. We're doing up to 16 a day. So our volume's pretty high. Initially, as you adopted this, were there any particular technologies that stood out to you? Um, I mean, we had a GE scanner before. So a lot of that, as far as the scanning part of it itself, was similar to what we had before. But this one does have some new features. Like I said, with the processing, really was a big thing for us. And also we have above us, which you guys, I don't know if you can see the top of the room, but we have a thing where it automatically will position a patient for us. So with that feature, it's really nice because you don't spend that extra two or three minutes in the room with the patient trying to get them in just the right position for the scan. So that will do that for you. It detects the patient's body on the table and will bring the table up, bring the patient in, and actually position them for you. So when you look at that over a 16-patient day, that really saved you that two or three minutes that you're up to five minutes sometimes, depending on the patient's size, can be in the room with the patient. It can increase your volume that way as well. I think a lot of the patients- Hang on, I can't hear you. I got you. Some of the patients' questions is claustrophobia. So we tried to deal with this. Most important thing is for us to see the patient beforehand and explain to them the procedure at the provider level. So when they come here, they're not worried about their claustrophobia. I think in the past two years, I've probably given only a couple of prescription of Xanax before the procedure. We explain to them the size of the circumference where the booth, we tell them the timing, and we also tell them that we're going to be there side by side. And with this new technology, it's going to be much lower acquisition time-wise and more accurate. And it's very important to explain to the patient that we want the most accurate test and the most sensitive and specific test for what we're looking for. So that's very important. When you tell them, I'm looking for the best test for you, even a claustrophobic patient wants to have the best results for themselves. Can you speak to how many tests work on this in a day when you do see 16 patients? Wait for that. Go ahead. So we, you're good? Okay. We at all times have two techs in the building here. One is usually primarily doing the scanning portion of it. And then the second hand or the second tech is the one bringing the patients back, prepping the patients, usually the ones helping turn over the room as well while the other technologist is doing more of the processing and scanning part of it. So there's always two sets of hands. Thank you. Would you mind elaborating a little bit along those lines on the process from when the patient gets to the table and all the way through? Sure. So once we get the patient on the table, we hook them up to the EKG. And the first thing that we do is the CAT scan. So that is a very short part of the scan itself. It takes about, I would say 30 seconds to a minute at the most to do that quick one bed CT. And then at that point, they transition to the back, which is where the PET scanner part of it is at. At that point, we come in the room, we hook the patient up to the injector. We use Ruby fill here. So we hook them up to the injector once they're back there and we start the injection. We move, we go out of the room and then we start the first scan. Each scan takes seven minutes. So once the first seven minutes is finished, we do a little processing. We come in the room, check on the patient, take a blood pressure and get ready for the stress portion of it, which is the very end. So once we get the blood pressure and their baseline EKG, at that point, we'll come back in the room and inject the patient with the pharmacologic agent, whichever you choose to use. We use Lexiscan here. So once we do that, then we start the injector again and do the second scan, which is also seven minutes and monitor the patient through that second part of it for the stress. And I do want to bring a point up, Dr. Ashi mentioned it about the claustrophobic patients, because I know that's always a big concern, but with the new scanner, which we did not have with the old one, is that it has lights inside the bore. So you can adjust those lights. It can get really bright if they really want it to look open. I think you guys can maybe see it behind me, but you can also dim them as well, just depending on what your patient prefers. But that really has helped out a lot as well. Mm-hmm. I think that takes us to the next level, which is, what does that mean to the physicians who are responsible for the interpretation of these results? After this short period of scanning, let's go back to some fundamentals. So when we say PET scan, PET scan refers to positron emission tomography. This is what nature can, this is the maximum intensity of light that nature can give you before the nuclear reaction level. And this is great, because if you compare the positron emission energy that give us all these brisk, vivid, high-definition images compared to the older generation of, let's say, technetium or the other radioactive agents, they were playing in the zone of 70 to 60 millielectron volt. Let's say that's the level of light intensity. CT scan, the PET scan nowadays provide 540 milliequivalents. This is almost like six times more energy or more intensity of brisk images. For the interpretation of these images, this is the maximum what nature can give you. And this is why we were able to get this patient outcome, which is five folds better than I would say by doing any regular standard old-fashioned stress test. The amount of, the portfolio of procedures or diseases that we can actually examine by this machine is versatile. It's much more versatile than we ever had before. Between coronary artery disease, between to the next level of checking viability by doing the viability studies on those portions of the heart muscle that are still amenable for intervention or not. To the infiltrative disease processes, you mentioned something about sarcoid. Testing for the infiltrative heart diseases is getting a lot of momentum nowadays. There's new technologies to treat and they rely on us to make the diagnosis. So we are also in need for these kinds of tools that provide the versatility of testing. Adding to that, this very high definition CT scan image capacity of this machine, I think that gives us everything between quality and safety in addition to patient, which will work together for patient outcome. I believe most viewers will be able to see how clean, brisk, well-defined images of myocardial perfusion scan here with a PET scanner. This was a game changer for us. If anybody has an experience dealing with older generation of nuclear imaging studies, this is by far the best what you can get in this kind of endeavors. Could you speak to what patient conditions do you consider when deciding whether or not they'll benefit from PET scan? So PET scan is actually replacing the standard stress testing. So the same criteria that we use to evaluate patients who would require myocardial stress test or cardiac stress testing can be applied to using PET scan. The higher definition of, or the higher definition of images and the better rates of accuracy and efficacy in this test allows us to examine patients who were in the past not even be able to do so. For instance, patients who have advanced myocardial disease with bypass procedures, we always had struggle with them going to high definition findings. With this new technology, we can be very certain to the level of which graft is diseased, which part of the myocardium needs to be intervened on. In addition to the versatility of other disease processes that can be evaluated with this technology, I think we are just being able to serve more and more patients. So the higher BMI patients, large chested patients, as if I have my druthers is that, the payers would pay for PET scan. I would do PET scan on almost all my patients unless I'm looking for a functional capacity. If I'm looking for a perfusion problem, this is the solution. Because this is more what I call black and white, more clear, more crisp pictures. We've been talking about this device. We're talking about the OmniLegend, the 128-slice CT. Take a look at this patient that we have. This is a patient of mine, her and her husband for almost 26 years. She called me and she's having some chest pain with exertion. And so we did this stress test on her. This lady had a stress test only a couple of years ago, which was a regular stress test, which was normal. She's a heavy smoker. I said, come back, come over, we'll do a PET scan. As you can see on that images, they're very crisp, they're nice and clean. You can see the whole lateral wall is ischemic in this patient and it recovers real nicely, reperfusion very nicely. So this lady was a thin lady, but if you look at the next patient, for example, this is a patient who's a BMI way above 40 and we were able to do the scanning and you can see the nice, crisp, clean pictures on this images versus a nuclear scan, regular nuclear scan. So large BMIs is important. Previous patient, if your clinical scenario is more to suggest the patient has coronal disease than not have coronal disease, I want the more accurate test. So I would go for the PET scan if the insurance doesn't pay. And we have uncertain patients actually where the insurance didn't wanna pay for it. They would pay for a stress test, but we're still suspicious. We did a PET scan, we took the head, we swallowed it, and we found that the patient has, then we call the insurance again and say, hey, we did it on our cost and your patient has this. It's either, you know, we're gonna go for a cardiac cath. So that's, you know, that's the kind of confidence that we have with this. Speaking of cardiac cath, have you noticed with this PET camera, have you seen it affect your positive cath rates compared to spasticity? 100%, it has. We rarely nowadays send patients for cath without, you know, proper imaging studies. And since we have introduced PET scan and Dr. Ashi mentioned, this has been our motto for the last five years, five, six years. Our percentage in our local market, in the local hospital practice that we do of false positive testing has dropped dramatically down to almost, you know, less than 1%. In fact, this will give us not only an advantage in terms of defining patient population who need intervention or caths, but also gives you a better terms with insurance companies, with Department of Transportation, for instance, Department of Health, FAA, because these tests have so much of an accuracy that if I have a normal stress test and a pilot, I can clear him to go back into his full duties based on these tests. While in the past, this was a multi-step, multi-stop process because, oh, the stress test was gray, not very accurate. So we had to do a calcium scoring. And then from calcium scoring, we go to a nuclear stress test and then a heart cath. If we can cut all these stops before we can clear someone to go back to a normal function or resume activities or go through surgical intervention with good reassurance that they will do fine, just fine by doing a single one-time stress test, I think that's a win-win situation. I think it has decreased the false positive, but also has also picked up the false negatives. So patients who were false negative on a previous testing modality, for example, we get these patients who are negative stress echoes and patients still having symptoms. They come to us for a second opinion. We do a PET scan. You know, other modalities that are false negative, we are picking them up here as a, you know, accurately with the PET scan. You also get that, you wanna talk about the myocardial blood flow that you get in addition to? So the newer technology now that we've been adapted is allow us not only to have these brisk, high-definition vivid images of the myocardial perfusion, but the system is so smart now, it can actually plug time to flow on a graph and give us something like a fractional flow stress test to the myocardial segments. In other words, the technology that allows for a differential blood flow measurement along the different coronaries through different myocardial segments, it's basically another layer of accuracy in determining the blood flow. And this is quite important because we struggled for such a long time with what we call as balanced ischemia, where the pictures look okay, but that doesn't mean that there's no blockage because a coronary artery disease at different levels, or if it involves all coronaries, will give you the same images in terms of nuclear perfusion scan, whether the patient does have a stress or rest imaging performed. And that was a situation where we would have missed patients who have a very serious cardiac problem, a coronary artery disease, and being unnoticed. By having this capacity of the accurate measurement of flow with time, we actually could tell which blood vessel, which coronary artery filled first, and which one has a delayed filling. And that adds to the accuracy of the results. And many times the perfusion images, the static images will look okay, but when we go and analyze the blood flow across the coronary arteries, we will pick up the multivessel disease or a single vessel branch disease that might not been seen in a routine stress test. So it's all integrated, plethora of data that can be used to make good clinical decision. And the more data, the more information I have, the better decision I will make. And I think that adds up into the whole global advantage of integrating PIP technology with versatile testing capacity and being able to image everything you do through a CT scanner that's all integrated in one system, I think that's a winner. Thank you all. We do have a number of questions from the audience that I'd like to share with you. To start, what post-processing software do you guys use? Cedar-Sinai. We're using Cedar-Sinai, but the expert is here, so you know. Hang on, I'm calling. We do, we use Cedars. We already had that in place, so that's why we are continuing to use that, and we still do SPECT as well in the office two days a week, and so we had to keep that software for the SPECT, so we are using that for both. Thank you. Another question, going back to what you mentioned earlier, when you're doing 16 patients in a day, is that an eight-hour day? That is, the first patient is at eight o'clock, and the last patient scanned that day is at 3.15. So it roughly comes out to be about two patients an hour is how they're scheduled. Who monitors the ECG during the stress? Is it an RN, or if not, someone else? And then, second part of the question, any issues with a Lexiscan injection? So we, the nuclear technologist, monitor the ECG during the test, and if we, what was the second part of it, did you say? If there were any issues with a Lexiscan injection. Yeah. So we always have a physician in-house. We have the cath lab, which is right on the other side of the room here, and so there's always a physician there, so there's always someone just a few steps away, so if we run into an issue, we just grab them, or we have also cath lab nurses that are willing and there to help if we run into a problem. So you don't have to have two nuclear, you don't have to have two nuclear technologists at the same time. We have some, you know, the two days that we do regular nuclear stress tests, the other technologist goes there, we have also one of the cath lab technologists that are able to monitor, or a nurse can actually monitor and, you know, put the IVs, et cetera. Another question, what impact do you think that F-18-based cardiac abrasors are going to have on cardiovascular metabolism? I think this will be very important for viability studies. This allows us to examine the metabolic burden or activity of myocardial cells, or sometimes any adjacent tissues that could be also examined with that. There is a growing population of patients who have totally occluded coronary arteries, population of patients who've been just aging and getting to the point where they have tried bypass surgery, they have multiple stents, they have CTOs, being able to examine their viabilities will give us the best approach in managing those advanced coronary artery disease. So we have been using this to make sure the viability studies are there. A lot of surgical decisions or interventions on complex cases depends on these results. And that also helps us for management because most of those patients would suffer from congestive heart failure symptoms and being able to evaluate and treat viable tissues will bring their muscle function in a better level. That's probably one of the best approach you could do for ischemic cardiomyopathy. So I just wanted to make a point on that last question about us monitoring the tracings during the stress test. So our technologists here that we have, we are ACLS trained in addition to our BLS. So we have a little more advanced training than most of your nuclear technologists. So if you are doing them in-house and you don't have a stress tech or you don't have a nurse or a physician in the room with you, then it would be a good idea for you to have your nuclear techs go and get their ACLS so that they know what to look for and what to do if there is a problem. Could you elaborate a little bit on any maybe required certifications, additional certifications or trainings that might be needed for the BLS program? So if you're looking to get the Omni and you're wanting to do diagnostic CTs as well as your cardiac pets, your nuclear technologist will need to be dual certified. So they will need to have their CT license as well in order to do that in-house and give contrast. In the past, when we had the old scanner, we did not do diagnostic CTs. We just used that for the CT portion of it just for the imaging and for the positioning of the patient. And that is covered under the nuclear license. But if you have the newer system and you have the capability of doing CTs with contrast, then you would have to have a certified tech to do that. Other question we have, what were your key considerations when selecting a CT? Processing time, capacity or the quality of the images. And then the selling point was the CT scanner with the 128 slice and the AI. I think once we figured out that we have an AI system that can identify a lot of pathologies and a system that can also provide imaging. For us, we're expanding our field of looking into different things. For instance, in the past, if I would need to do a CT scan of the pulmonary artery with contrast, I would have to make an appointment in the hospital or one of the imaging centers, get the patient ready for a CT scan, make an appointment in two weeks. If I'm suspecting somebody with having a pulmonary embolism or something within that range of diagnosis, I need an answer, I need the answer now. So being able to do this under one ceiling in one place, along with my other cardiac work, I think that was a great advantage of upgrading to a better system. I know it's a financial advance, it's a financial burden, it's an investment that needs to be looked at and considered equally. But the amount of diseases that we can check for, the quality of the images that will give us the advantage of giving best advice to our patients, this is actually a good business model. And I can tell you, we actually interviewed other vendors. We looked at other vendors, but for almost a year, because we already had a CAT scan, PET scan, but it was only a 16 slice. We wanted to change the technology for the reasons he said, accuracy, CAT scan, et cetera, but we didn't take it lightly. We looked at three different vendors and we looked at who's gonna give us the best service, who's gonna give us, of course, the best price, but service and pricing was part of it. We already had a GE before and we have other GE equipment, ECHOs and vasculars and all that stuff. So it was a seamless transition to just have another GE unit, especially with the AI and hopefully this AI capability is gonna improve where you probably don't need a radiologist one day to read most of this. Another question from the audience, have there been any instances or examples at this facility where CT scans have helped to inform treatment strategies for calcified coronary lesions within the cath lab? We do quite a bit of a CT, coronary CTAs and along with calcium scoring, the capacity of the device to calculate calcium score in a lot of patients is important. I think that's one of the to-go tests for low risk patients nowadays in the community. CTA is another advantage examination of calcium, both these modalities, whether calcium scoring or coronary CTA, they rely heavily on calcium concentration in the lesions, which give us an idea of the obstructive or non-obstructive coronary artery disease. I think more and more that we are using more CTA, coronary CTAs. In fact, the most recent American Heart Association guidelines are elevating the use of and highlighting the use of CT coronary angios in managing acute chest pain in patients, whether it's the emergency room or in the doctor's offices to give best results with a short period of time and a single test to rule out multiple other pathologies. So we are using this more often and we are expecting to use it even more in the future. Do you fit any diagnostic CT into the 30 minute appointment times and then are any of them done after 3.15? We can fit them. We try to do the PET scans first and the CTs in the afternoon, but if the patients need to have a CAT scan or done early in the morning for one reason or other, we'll try to accommodate them. But yeah, we try to do the PET scans in the morning and the CAT scan in the afternoon. But we can, yes, you can interchange based on the patient. The nice thing to have this CAT scan is next to a cath lab that's very busy cath lab. If we need a patient that's crashing and we wanna know if they have a retroponial bleed, we can just bring him here, get a CAT scan instead of taking him to the hospital, get a CAT scan and then go back and fix them. Here, we can take it immediately, get a CAT scan and take him back to the table and fix them. This is the nice thing about having it all under one roof. All we have is a wall between us and the cath lab. And what percentage of PET versus CT is performed? I think as we are rolling this technology furthermore, we're still probably 65% PET scanning of the technology. At some point, I think we're gonna be at probably 50, 50% based on the volume of patient that would require more and more. We just started enrolling patients, for instance, with abdominal aneurysm into this six months or 12 months routine checkup. So by the time you accommodate more patients, this will change the ratio as we move forward. The habits take some time, but once those habits, I mean, I still personally struggle. So like, should I send the patient to the hospital? Oh, and then I remember that, oh, we have even a better scanner here than the hospital. Let me utilize that. I think by the time, I would say six months from now, we might be just breaking even 50, 50% of the time. I'll be honest with you, we're busy enough to do that, but I think by the time we get to that point, I'll be honest with you, we're busy enough that eventually, not eventually, but we are opening sometimes on Saturdays to catch up. So CAT scans eventually will be done with a part-time person to come in the afternoon and Saturdays because we just started doing the CAT scans in the last only couple of months, but CAT scans, we've been doing it for many years. But because of this technology, now we're starting to do CAT scan. We started doing them slowly, but we have enough volume to keep it busy, maybe six, seven studies a day. That's our goal. Along those lines, how did you set up your facility to handle high patient volumes? This has been 26 years in the making. So I've been here 26 years. We did a lot of, you know, I've had a couple of other practices there, but this is, all the patients follow me, obviously, and now the whole practice. But we do a lot of marketing. We have a conference, a CME conference that we hold. There's about 400 to 600 primary care physicians, providers come in from every specialty. We educate them about cardiovascular disease, but we are inclusive of all other specialties, ophthalmology, radiology. So we all get together for four days. We get about 40 hours of CME. So educating other people, primary care physicians, providers, they're gonna start sending patients. They're gonna better serve their own patients by finding the right, the advanced technology, they're finding the right physician for their patients. You know, we pride ourselves about having one of the lowest amputations, the best outcomes for peripheral vascular disease below the knee. You know, we pride ourselves, and that's based on CPT codes. We pride ourselves on, you know, having one of the best services for DVTs and PEs with this equipment, with the ultrasound, plus, you know, CAT scan, venography, or MRI venography, and we have a lab, you know, that's how we advertise. But we're inclusive of structural. We have EP, we have very strong vascular, endovascular group, five guys. We have non-invasive. We had a very strong echo lab, vascular lab, cath lab, and now this PET scan, CAT scan. So, and you just have to keep advertising. You have one more question from the audience. From the CT side of things, are you utilizing FFR? And if so, have you seen any reduction in orders for diagnostic cath due to this improved cath lab and accuracy and efficiency? So the quick answer is not yet. We, the FFR, IFR technology with CT imaging is still, I believe, in some sort of infancy itself. And it's very much of something that relies on CoreLab, which, in other words, you do the imaging somewhere, but they have to send those images somewhere else. Most of the time, this is a hospital level cost of treatment. So the answer is not yet. I think it's going to become a standard and or become an option in the near future. But right now, this is all very, very exclusive testing that's done through a third-party CoreLab. You know, you have, you take the images and we like to be distinguished by being able to give the patient the best advice on a speedy manner. If I'm going to wait, you know, three days before the results are back, I failed myself and I failed my patient. And I think also the technology is prohibitive cost-wise for an outpatient. Maybe the hospital wants to absorb that technology, but I don't think it's serving our patients any more than what. If you do a good history and physical, you're a good cardiologist, you're a good provider, you have a nice PET scan. And if it's positive and you have a positive history, I'm not sure I need an IFR that costs more than the CAT scan. So I'm a little hesitant on using tech. If it was, you know, pennies to the dollar to add to the patient cost, either a hospital outpatient, I would consider it. But as you said, it takes three days to process it. It's very expensive. They have all the rights for it and you have no control over the patient. But if you have a good history and physical, you have a PET scan, you have an echo, you have all the risk factors, I'm not sure an IFR is going to add. The PET scan is positive, he's going to get a cath. Okay. Well, I would like to thank you. Well, that was a very interesting talk. We appreciate you. Of course, Leon. So I would like to thank you, Dr. Ashi, for putting this together. Yes, thank you so much, Dr. Ashi, Dr. Bisharat and as well, Ashley Byrd. Thank you so much for being here with us today. We greatly appreciate it and for sharing your story from Ashi Heart regarding PET. So with that, we will conclude today's webinar and you will hear from us as we follow up shortly with a link to this, if you came in a little bit late and also with the deck. So thanks everybody. Appreciate it. Have a great one. Bye-bye.

webinar

Ashi Heart and Vascular

GE Healthcare

MedAxion

Utilizing Novel Digital PET-CT Technology to Elevate Cardiac Patient Care

PET-CT technology

cardiac imaging

OmniLegend

128-slice CT scanner