Routine Intracoronary Imaging-guided Left Main Coronary Intervention

Background Left main (LM) percutaneous coronary intervention (PCI) with routine intracoronary imaging guidance is recommended; however, its real-world effectiveness remains unclear. This study aimed to investigate the outcomes in a Japanese National Hospital Organization cohort in which routine imaging guidance was adopted. Methods Of the 806 consecutive patients undergoing drug-eluting stent implantation for de novo unprotected LM lesions across 19 hospitals, 743 were analyzed after excluding 63 owing to criteria mismatch or incomplete follow-up. The primary endpoint was 1-year major adverse cardiovascular and cerebrovascular events (MACCE), comprising all-cause death, cerebrovascular disorder, clinical-driven revascularization, and myocardial infarction. Results The cohort exhibited increased prevalences of diabetes mellitus, prior myocardial infarction, and prior revascularization. Acute coronary syndrome was present in 31.2% of the patients, with 39.3% classified as Canadian Cardiovascular Society functional angina (CCS) class ≥III. LM bifurcation lesions were observed in 78.0% of the patients, with two-stent implantation in 8.8% of the patients. MACCE occurred in 17.5% of the patients, with target lesion revascularization and cardiac death rates of 2.0% and 3.4%, respectively. Independent risk factors for MACCE included CCS class ≥III (hazard ratio [HR], 2.07), mechanical cardiac support device use (HR, 2.17), two-stent implantation (HR, 2.49), 10% increase in left ventricular ejection fraction (HR, 0.72), and radial access (HR, 0.62). Conclusion Routine imaging-guided LM-PCI is associated with a lower incidence of target lesion revascularization and cardiac death. However, severe left ventricular dysfunction and multiple-vessel involvement are associated with higher mortality and revascularization risks, requiring comprehensive management beyond imaging-guided PCI. Clinical Perspective What is new? This study clarifies the clinical outcomes of left main coronary intervention guided by routine intracoronary imaging, revealing a low frequency of target lesion revascularization and cardiac death. Despite the favorable local efficacy of imaging guidance, patients with severe left ventricular dysfunction and multiple-vessel involvement still face elevated risks of mortality and revascularization. What are the clinical implications? Intracoronary imaging guidance in the left main coronary artery is crucial for optimizing intervention treatments and enhancing local efficacy at the treated sites. Despite these improvements, the high mortality rate associated with serious myocardial damage from left main coronary artery obstruction underscores the importance of careful consideration in such cases. Coronary artery disease involving the left main and multiple vessels carries an elevated risk of additional revascularizations beyond the target lesion, emphasizing the need for comprehensive management strategies.