Optimal Intravascular Ultrasound-Guided Percutaneous Coronary Intervention in Patients With Left Main Coronary Artery
Ryusuke Nishikawa1, Hiroki Shiomi1, Ko Yamamoto2
1Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
Insights
Optimal intravascular ultrasound (IVUS)-guided left main coronary artery (LMCA) percutaneous coronary intervention (PCI) showed favorable 1-year outcomes. This approach achieved significantly lower cardiovascular events than the PCI performance goal.
Area of Science:
- Interventional Cardiology
- Cardiovascular Imaging
- Clinical Outcomes Research
Background:
- Intravascular ultrasound (IVUS) guidance for left main coronary artery (LMCA) percutaneous coronary intervention (PCI) requires further outcome evaluation.
- Optimal IVUS criteria for LMCA PCI have been proposed but not extensively validated.
Purpose of the Study:
- To evaluate the clinical outcomes of LMCA PCI performed using optimal IVUS guidance according to prespecified criteria.
- To compare the outcomes against predefined performance goals based on historical PCI and coronary artery bypass grafting (CABG) data.
Main Methods:
- A prospective, multicenter, single-arm trial (OPTIVUS-Complex PCI study LMCA cohort) enrolled 902 patients undergoing LMCA PCI.
- Patients were treated targeting specific IVUS criteria for minimal stent area.
- The primary endpoint was a composite of death, myocardial infarction, stroke, or any coronary revascularization at 1 year.
Main Results:
- The prespecified IVUS criteria were met in 73.7% of patients.
- The 1-year cumulative incidence of the primary endpoint was 13.2%, significantly lower than the PCI performance goal (32.0%) and numerically lower than the CABG goal (13.9%).
- Patients meeting IVUS criteria had significantly lower target-lesion revascularization rates (3.3% vs 7.7%).
Conclusions:
- Optimal IVUS-guided LMCA PCI in contemporary practice is associated with significantly better clinical outcomes compared to historical PCI benchmarks.
- This approach demonstrated a numerically favorable outcome compared to CABG performance goals.
- Adherence to optimal IVUS criteria may reduce the need for revascularization procedures.
Abstract:
The impact of optimal intravascular ultrasound (IVUS)-guided left main coronary artery (LMCA) percutaneous coronary intervention (PCI) on clinical outcomes has not been adequately evaluated yet. The OPTIVUS-Complex PCI study LMCA cohort was a prospective multicenter single-arm trial enrolling 902 patients undergoing LMCA PCI targeting the prespecified IVUS criteria (minimal stent area ≥5.0 mm2 for left circumflex artery ostium, ≥6 mm2 for left anterior descending coronary artery ostium, ≥7 mm2 for polygon of confluence, and ≥8.0 mm2 for proximal LMCA). The primary endpoint was a composite of death, myocardial infarction, stroke, or any coronary revascularization. The predefined performance goals were based on the CREDO-Kyoto PCI/coronary artery bypass grafting (CABG) registry cohort-2 (PCI: 32.0%, and CABG: 13.9%). The OPTIVUS criteria were met in 73.7% of patients. The prevalence of true bifurcation LMCA lesion was 18.4%. The cumulative 1-year incidence of the primary endpoint was 13.2% (95% CI 11.0% to 15.4%), which was significantly lower than the PCI performance goal (32.0%, p <0.0001), and numerically lower than the CABG performance goal (13.9%). The cumulative 1-year incidences of target-lesion revascularization and target-lesion revascularization for LMCA lesions were 4.2% and 3.0%. The cumulative 1-year incidence of the primary endpoint was not different regardless of meeting or not meeting the OPTIVUS criteria (13.4% vs 14.2%, log-rank p = 0.79), while those of target-lesion revascularization and target-lesion revascularization for LMCA lesions were significantly lower in patients meeting the OPTIVUS criteria than in patients not meeting the OPTIVUS criteria (3.3% vs 7.7%, log-rank p = 0.01, and 2.3% vs 5.5%, log-rank p = 0.02). In conclusion, IVUS-guided LMCA PCI targeting the OPTIVUS criteria in the contemporary clinical practice was associated with a significantly lower rate of cardiovascular event than the predefined PCI performance goal, and with a numerically lower rate of cardiovascular event than the predefined CABG performance goal at 1 year.
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