Optical coherence tomography guidance for the management of angiographically intermediate left main bifurcation lesions: Early clinical experience

Background: Leftmain (LM) atherosclerotic lesions affect clinical outcomes. Frequency domain-optical coherence tomography (FD-OCT) allows detailed characterization of non-ostial coronary atherosclerotic lesions. The clinical impact of FD-OCT assessment of LM bifurcation disease on the revascularization decision is unknown. Methods: Patients who underwent FD-OCT assessment to guide management of angiographically intermediate distal LM stenosis were retrospectively selected. The FD-OCT LM criteria for percutaneous or surgical revascularization were: -LM area stenosis (AS) >= 75% -LM AS >50%< 75% with minimum lumen area < 4 mm(2) or plaque ulceration -critical FD-OCT ostial stenosis on the left anterior descending or circumflex arteries. Clinical follow-up was obtained to evaluate the occurrence of target vessel failure (TVF) defined as cardiac death and/or acute myocardial infarction (AMI) not related to other vessel and/or target vessel revascularization. Results: Out of 131 patients underwent FD-OCT assessment of LM, 122 patients (93%) entered the study. Based on FD-OCT features, 58 (48%) patients were conservatively managed, while the remaining 64 (52%) were revascularized by stenting (n= 48) or surgery (n= 16). After a mean follow-up of 18 months, TVF-free survival was not different between patients undergoing conservative management vs. revascularization (HR 0.40, CI 95% 0.10-1.61, P = 0.20). Of note, two patients only in the conservative management group had TVF (elective LM stenting, no death or myocardial infarction). Conclusions: This preliminary experience suggests that a FD-OCT based management for patients with angiographically-intermediate LM bifurcation stenosis may help identify patients in whom revascularization could be deferred. Such observation calls for further evaluations by appropriately designed trials. (C) 2017 Elsevier B.V. All rights reserved.