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Intravascular ultrasound-guided treatment for angiographically indeterminate left main coronary artery disease: a
Amir-Ali Fassa1, Kenji Wagatsuma, Stuart T Higano
1Center of Coronary Physiology and Imaging, Cardiac Catheterization Laboratory, Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
Insights
Intravascular ultrasound (IVUS) accurately assesses indeterminate left main coronary artery (LMCA) disease. Deferring revascularization for patients with a minimum lumen area (MLA) of 7.5 mm² or greater is safe and effective.
Area of Science:
- Cardiology
- Medical Imaging
- Interventional Cardiology
Background:
- Coronary angiography can be challenging for assessing left main coronary artery (LMCA) lesions.
- Intravascular ultrasound (IVUS) provides valuable data for evaluating coronary artery disease.
Purpose of the Study:
- To determine the efficacy of an IVUS-guided strategy for managing patients with indeterminate LMCA disease.
- To establish a reliable minimum lumen area (MLA) threshold using IVUS for LMCA lesion assessment.
Main Methods:
- IVUS was used to define the lower limit of normal MLA in 121 patients with normal LMCAs.
- IVUS was performed on 214 patients with indeterminate LMCA lesions, guiding revascularization decisions based on MLA.
- A predetermined MLA threshold was used to recommend deferral of revascularization.
Main Results:
- The lower range of normal LMCA MLA was determined to be 7.5 mm².
- 83 patients (38.8%) had an MLA <7.5 mm², undergoing revascularization (85.5%).
- 131 patients (61.2%) had an MLA ≥7.5 mm², with revascularization deferred (86.9%).
- No significant difference in major adverse cardiac events was observed between the groups after a mean follow-up of 3.3 years.
- The optimal MLA cut-off for predicting outcomes was 9.6 mm².
Conclusions:
- IVUS is an accurate tool for assessing indeterminate LMCA lesions.
- Deferring revascularization in patients with an LMCA MLA ≥7.5 mm² is a safe strategy.
- Age, smoking, and non-LMCA vessel disease are predictors of cardiac events.
Objectives:
The purpose of this study was to evaluate the efficacy of an intravascular ultrasound (IVUS)-guided strategy for patients with angiographically indeterminate left main coronary artery (LMCA) disease.
Background:
The assessment of LMCA lesions using coronary angiography is often challenging; IVUS provides useful information for assessment of coronary disease.
Methods:
Intravascular ultrasound was performed on 121 patients with angiographically normal LMCAs to determine the lower range of normal minimum lumen area (MLA), defined as the mean - 2 SD. We conducted IVUS studies on 214 patients with angiographically indeterminate LMCA lesions, and deferral of revascularization was recommended when the MLA was larger than this predetermined value.
Results:
The lower range of normal LMCA MLA was 7.5 mm(2). Of the patients with angiographically indeterminate LMCAs, 83 (38.8%) had an MLA <7.5 mm(2), and 131 (61.2%) an MLA > or =7.5 mm(2). Left main coronary artery revascularization was performed in 85.5% (71 of 83) of patients with an MLA <7.5 mm(2) and deferred in 86.9% (114 of 131) of patients with an MLA > or =7.5 mm(2). Long-term follow-up (mean 3.3 +/- 2.0 years) showed no significant difference in major adverse cardiac events (target vessel revascularization, acute myocardial infarction, and death) between patients with an MLA <7.5 mm(2) who underwent revascularization and those with an MLA > or =7.5 mm(2) deferred for revascularization (p = 0.28). Based on outcome, the best cut-off MLA by receiver operating characteristic was 9.6 mm(2). Multivariate predictors of cardiac events were age, smoking, and number of non-LMCA vessels diseased.
Conclusions:
Intravascular ultrasound is an accurate method to assess angiographically indeterminate lesions of the LMCA. Furthermore, deferring revascularization for patients with a minimum lumen area > or =7.5 mm(2) appears to be safe.
