Monotherapy with a potent P2Y12 receptor antagonist after 1 month of dual antiplatelet therapy (DAPT) may reduce bleeding in the absence of increased ischaemic events compared to 12-month DAPT in patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI). PCI guidance with optical coherence tomography (OCT) may enhance stent expansion. COMPARE STEMI ONE is an international, multicentre, open-label, randomised controlled trial. In 1,656 ST-segment elevation myocardial infarction (STEMI) patients, prasugrel monotherapy after 1 month of DAPT, as compared to standard 12-month prasugrel-based DAPT, will be tested for non-inferiority for the primary composite endpoint of net adverse clinical events - defined as all-cause death, myocardial infarction, stroke, or Bleeding Academic Research Consortium Type 3 or 5 bleeding events - at 11 months after randomisation. Furthermore, an ancillary substudy will test the superiority of OCT-guided versus angiography-guided staged complete revascularisation in achieving a larger minimal stent area (MSA) in non-culprit lesions during staged procedures. COMPARE STEMI ONE is the first randomised controlled trial assessing an abbreviated 1-month DAPT regimen followed by prasugrel monotherapy in the context of STEMI. The trial will also study the value of OCT-guided PCI in terms of the MSA of non-culprit lesions and may elucidate potential synergies between intravascular imaging-guided PCI and abbreviated DAPT regimens. (ClinicalTrials.gov: NCT05491200).

Intravascular imaging with intravascular ultrasound (IVUS) or optical coherence tomography (OCT) may guide stent sizing and placement during percutaneous coronary intervention (PCI). We compared IVUS- vs. OCT-guided PCI in terms of mechanical outcomes.

PubMed, Embase and Cochrane databases were systematically searched until December 2024 for randomized controlled trials (RCTs) comparing IVUS- vs. OCT-guided PCI. Random-effects models were used to estimate mean differences (MDs) and standard mean differences (SMDs) with 95 % confidence intervals (CIs).

Six RCTs with 2696 patients were included; 1396 (49.6 %) underwent IVUS-guided PCI. The mean age was 65.1 ± 10.2 years. In the pooled analysis, the post-PCI minimum stent area (MSA) was significantly higher with IVUS-guided PCI than with OCT-guided PCI (MD 0.64 mm2; 95 % CI 0.17-1.10; p < 0.01), and post-PCI mean diameter stenosis was significantly lower with IVUS (MD -1.05 %; 95 % CI -1.90 to -0.21; p = 0.01). There were no significant differences between groups in acute lumen gain, stent expansion index, malapposition, tissue protrusion, or edge dissection. In a subgroup analysis, IVUS-guided PCI yielded a greater MSA in studies that did not size vessels by measurement of the external elastic membrane. However, trial sequential analysis suggested that the RCTs to date have not reached the required quantity of information to support definitive conclusions about MSA and mean diameter stenosis.

This meta-analysis demonstrated that IVUS-guided PCI was associated with greater MSA and reduced diameter stenosis compared to OCT-guided PCI, with no difference in stent expansion index, more trials are required to confirm this hypothesis.

Data regarding the proportion and clinical impact of achieving stent optimization by intravascular ultrasound (IVUS)- or optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) remain limited.

The authors assessed the proportion and cardiovascular outcomes in patients with and without stent optimization using imaging guidance.

This secondary analysis of the OCTIVUS (Optical Coherence Tomography-Guided or Intravascular Ultrasound-Guided Percutaneous Coronary Intervention) trial classified patients into optimized (meeting all prespecified optimization criteria) or nonoptimized groups. The primary endpoint was target vessel failure (TVF), a composite of cardiac death, target vessel myocardial infarction, or ischemia-driven target vessel revascularization.

Among 1,980 patients, 1,022 (51.6%) achieved stent optimization, with a lower proportion in the OCT-guided group than in the IVUS-guided group (467 of 967 [48.3%] vs 555 of 1,013 [54.8%]; P = 0.004). At a median follow-up of 2.0 years, TVF incidence was lower in the optimized group than in the nonoptimized group (39 of 1022 [3.8%] vs 72 of 958 [7.5%]; HR: 0.52; 95% CI: 0.35-0.77; P < 0.001). The effect of stent optimization on TVF appeared more substantial in OCT-guided PCI (14 of 467 [3.0%] vs 38 of 500 [7.6%]; HR: 0.39; 95% CI: 0.21-0.72) than in IVUS-guided PCI (25 of 555 [4.5%] vs 34 of 458 [7.4%]; HR: 0.63; 95% CI: 0.37-1.05), albeit there was no significant interaction between TVF and imaging modalities (P for interaction = 0.30).

Stent optimization was achieved in approximately one-half of patients undergoing imaging-guided PCI and was associated with a better clinical outcome. This effect appeared more pronounced in OCT-guided than in IVUS-guided PCI. (Optical Coherence Tomography Versus Intravascular Ultrasound Guided Percutaneous Coronary Intervention [OCTIVUS]; NCT03394079).

Intravascular ultrasound (IVUS) or optical frequency domain imaging (OFDI) for guiding percutaneous coronary interventions (PCI) reduces the risk of adverse events compared with angiographic guidance. However, only a few trials compared both modalities. This study aims to assess and compare OFDI- vs. IVUS-guided PCI. We conducted a meta-analysis of randomized controlled trials (RCTs) retrieved from PubMed, Scopus, WOS, Embase, and Cochrane Library till September 2024. The primary outcome was major adverse cardiac events (MACE). Risk ratios (RR) were applied for dichotomous outcomes and mean differences (MD) for continuous outcomes, both with 95% confidence intervals (CI). PROSPERO ID: CRD42024595477. Four RCTs with 1135 patients were included. There was no significant difference between the two modalities in terms of MACE [RR: 0.99; 95% CI: (0.53, 1.86); P = 0.98], all-cause mortality [RR: 0.72; 95% CI: (0.15, 3.56); P = 0.69], cardiac mortality [RR: 1.00; 95% CI: (0.18, 5.68); P = 1.00] and myocardial infarction [RR: 1.21; 95% CI: (0.35, 4.18); P = 0.76]. Additionally, there was no significant difference in PCI success [RR: 1.00; 95% CI: (0.99, 1.02); P = 0.64]. However, OFDI was associated with a significant increase in contrast volume [MD: 19.81 ml; 95% CI: (2.53, 37.09); P = 0.02] and reduction in fluoroscopy time [MD: -7.05 min; 95% CI: (-9.32, -4.79); P < 0.01]. This meta-analysis of RCTs suggests that OFDI is comparable to IVUS in efficacy and safety for guiding PCI, with no significant differences in clinical outcomes. These findings support the use of either modality for PCI guidance. However, additional large-scale, multicenter RCTs to recommended to validate these findings and enhance their generalizability.

The impact of lipid core burden index (LCBI) after percutaneous coronary intervention (PCI) in the stented segment assessed by intracoronary near-infrared spectroscopy on the outcomes remains unclear.

In this prospective observational study, we aimed to assess the impact of post-PCI LCBI on late luminal loss and clinical outcomes. Post-PCI intracoronary near-infrared spectroscopy imaging was performed in the stented segment after PCI. Patients were categorized into 2 groups based on the post-PCI maxLCBI4mm with a cut-off value of 200. Angiographic and clinical outcomes were compared at 12 months. The primary end point was angiographic late luminal loss. The secondary end point was target lesion failure (composite of cardiovascular death, target vessel myocardial infarction, and clinically driven target lesion revascularization) and major adverse cardiac and cerebrovascular events (composite of cardiac death, myocardial infarction, any repeat revascularization, and stroke).

A total of 228 patients with 278 target lesions were followed up for 1 year. One-year follow-up angiography was performed on 198 lesions in 163 patients. Follow-up quantitative coronary angiography revealed that stented segments with post-PCI maxLCBI4mm ≥200 had higher late luminal loss compared with those with a post-PCI maxLCBI4mm <200 (mean, 0.503±0.683 mm versus 0.115±0.326 mm; P<0.001; median, 0.250 mm versus 0.050 mm; P<0.001). Patients with post-PCI maxLCBI4mm ≥200 had a significantly higher 1-year cumulative incidence of both target lesion failure (6.9% versus 0.6%; P=0.002) and major adverse cardiac and cerebrovascular events (15.1% versus 2.2%; P<0.001).

Post-PCI LCBI assessed by intracoronary near-infrared spectroscopy-intravascular ultrasound was associated with late luminal loss as well as subsequent target lesion failure and major adverse cardiac and cerebrovascular events.

Background/Objectives: Despite the potential benefits, intravascular imaging for guiding percutaneous coronary intervention (PCI) remains underutilized. Recent trials have provided new data, prompting a need for updated insights. This study aimed to perform a comprehensive meta-analysis to compare the clinical outcomes of intravascular imaging-guided PCI versus angiography-guided PCI, thereby evaluating the relative effectiveness of these two guidance strategies in improving patient outcomes. Methods: PubMed, Cochrane Library, Embase and Clinicaltrials.gov databases were systematically searched from inception till 25 November 2024. Randomized clinical trials (RCTs) comparing intravascular imaging with coronary angiography in patients undergoing complex PCI were included. Statistical analysis was conducted using a random effects model to calculate pooled risk ratios with 95% confidence intervals (CI). Results: In this meta-analysis of 21 studies involving 18,043 patients, intravascular image-guided PCI significantly reduced the risk of all-cause mortality by 24%, cardiac mortality by 63%, MACE by 35%, target vessel myocardial infarction by 32%, stent thrombosis by 42%, target vessel revascularization by 45%, target lesion revascularization by 34% and myocardial infarction by 22% compared to angiography-guided PCI. There was no significant difference in bleeding events. Conclusions: Intravascular imaging significantly reduces cardiac events, all-cause mortality and revascularization rates in PCI patients. These findings support its broader adoption and potential updates to clinical guidelines.

Optical coherence tomography (OCT) provides high-resolution intracoronary imaging. However, whether the addition of OCT to angiography to guide percutaneous coronary intervention (PCI) of complex lesions affects clinical outcomes is debated.

A systematic search for randomized controlled trials was conducted using PubMed, Scopus, and Cochrane databases through September 2024. End points included major adverse cardiovascular events, cardiac death, myocardial infarction, periprocedural myocardial infarction, all-cause mortality, stent thrombosis (definite or probable), and target-vessel revascularization. The random-effects model was used to generate risk ratios (RRs) and 95% CIs.

A literature search identified 4 randomized controlled trials including 5603 patients with a median follow-up of 2 years. Compared with PCI guided by angiography alone, OCT-guided PCI was associated with lower major adverse cardiovascular events (RR, 0.68 [95% CI, 0.55-0.84]; P<0.001), cardiac death (RR, 0.43 [95% CI, 0.24-0.76]; P=0.003), myocardial infarction (RR, 0.75 [95% CI, 0.59-0.96]; P=0.02), all-cause mortality (RR, 0.58 [95% CI, 0.38-0.87]; P=0.009, and stent thrombosis (RR, 0.49 [95% CI, 0.26-0.90]; P=0.02). There was a trend toward lower target-vessel revascularization (RR, 0.67 [95% CI, 0.44-1.03]; P=0.07) and lower periprocedural myocardial infarction (RR, 0.79 [95% CI, 0.59-1.06]; P=0.11) with OCT guidance compared with angiography alone.

The addition of OCT guidance to PCI of complex lesions resulted in better clinical outcomes than angiography guidance alone. Updated guidelines should strengthen recommendations supporting the use of OCT guidance for complex PCI.

URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42024603847.

As patients increase in age and medical complexity, coronary artery calcification is frequently encountered and its presence portends worse outcomes following percutaneous coronary intervention (PCI) - negatively impacting procedural success and long-term outcomes. This review paper explores available imaging techniques and calcium modification technique that can identify, characterize and modify these lesions to facilitate stent implantation. The data supporting these techniques are explored and an algorithm for decision-making during lesion modification is presented. Current barriers and future directions are additionally discussed.

Intravascular ultrasound (IVUS) provides precise anatomic information in coronary arteries including quantitative measurements and morphological assessment. To standardize the IVUS analysis in the current era, this updated expert consensus document summarizes the methods of measurements and assessment of IVUS images and the clinical evidence of IVUS use in percutaneous coronary intervention.

Coronary artery disease (CAD) remains a major contributor to the global mortality rate. Accurate and detailed evaluation of atherosclerotic plaque characteristics is essential for effective risk assessment and treatment planning. Although conventional coronary angiography excels at quantifying luminal stenosis, information on plaque composition and structure remains limited. Recent advances in intravascular imaging (IVI) have bridged this gap by enabling high-resolution visualization of the vessel wall and plaque morphology, thereby enhancing treatment strategies and facilitating comprehensive risk stratification. Among the principal IVI modalities, intravascular ultrasound (IVUS), optical coherence tomography (OCT), and near-infrared spectroscopy (NIRS) provide distinct benefits. IVUS accurately measures vessel diameter and plaque burden, offering critical guidance for managing complex lesions and left main artery disease. The extremely high spatial resolution of OCT allows precise identification of high-risk plaque features, such as thin fibrous caps. NIRS complements these techniques by quantitatively assessing lipid components within plaques, making it particularly useful in predicting future cardiovascular events. In this review, we summarize the latest evidence on applying IVI modalities to the evaluation and treatment of CAD. We focus on the assessment of plaque morphology, identification of high-risk lesions, and the role of IVI-guided percutaneous coronary intervention (PCI). The continued development of hybrid imaging systems and artificial intelligence-based image analysis may produce more precise and safer PCI approaches. Consequently, IVI is poised to become indispensable in managing CAD, paving the way for more personalized treatment strategies tailored to the specific lesion characteristics of each patient.

The results of randomized clinical trials comparing the outcomes of different strategies for driving PCI are mixed, and it remains unclear which technique for driving PCI offers the greatest benefit. The aim of the study was to compare the clinical efficacy of different techniques to guide percutaneous coronary intervention (PCI).

We search major electronic databases for randomized clinical trials evaluating clinical outcomes of PCI with stent implantation guided by coronary angiography (CA), fractional flow reserve (FFR), instantaneous wave-free ratio (iFR), intravascular ultrasound (IVUS) and optical coherence tomography (OCT). The primary outcome was cardiac death.

The results from 39 randomized trials (29,614 patients) were included in the network meta-analyses. Compared with CA, the use of OCT (RR: 0.33, 95 % CI: 0.19-0.54), IVUS (RR: 0.47, 95 % CI: 0.31-0.71) and FFR (RR: 0.61, 95 % CI: 0.38-0.97) were associated with reduced risk of cardiac death; there were no differences between OCT, IVUS and OCT was ranked as the best strategy. PCI guidance using OCT, FFR and IVUS was also associated with a reduction of myocardial infarction. The use of OCT or IVUS for PCI guidance was associated with a significant reduction in target lesion failure, target vessel revascularization, target lesion revascularization and stent thrombosis, compared with CA. OCT-guided PCI was associated with a significant reduction in all-cause death compared with CA-guided PCI and with a reduction in TLF compared with FFR- and iFR-guided PCI. Pooled estimates were mostly consistent across several sensitivity analyses.

Compared with angiography-guided PCI, both an intravascular imaging-guided strategy and a physiology-guided strategy are associated with better clinical outcomes.

Intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) reduces the risk for clinical events in patients with acute coronary syndromes (ACS), compared with angiographic guidance. However, the benefits of IVUS guidance in high-risk patients with diabetes with ACS is uncertain.

The aim of this prespecified stratified subgroup analysis from the IVUS-ACS randomized trial was to determine the effectiveness of IVUS-guided PCI vs angiography-guided PCI in patients with diabetes with ACS.

From August 20, 2019, to October 27, 2022, 1,105 patients with diabetes with ACS were randomized, including 554 patients in the IVUS-guided group and 551 in the angiography-guided group. The primary endpoint was the rate of target vessel failure (TVF) at 1 year, defined as the composite of cardiac death, target vessel myocardial infarction, or clinically driven target vessel revascularization.

At 1-year follow-up, TVF occurred in 20 patients in the IVUS guidance group and in 46 patients in the angiographic guidance group (Kaplan-Meier rates 3.6% vs 8.3%; HR: 0.46; 95% CI: 0.27-0.81; P = 0.007), driven by a reduction in clinically driven target vessel revascularization (0.9% vs 3.8%; P = 0.003). IVUS-guided PCI also reduced the risk for TVF without procedural myocardial infarction (2.0% vs 6.7%; HR: 0.29; 95% CI: 0.15-0.57; P < 0.001) and all-cause mortality (HR: 0.30; 95% CI: 0.10-0.93; P = 0.037). There were no significant differences in the rates of stent thrombosis or major bleeding between the groups.

In the large-scale IVUS-ACS trial, IVUS-guided PCI improved 1-year clinical outcomes in high-risk patients with diabetes with ACS. (1-Month vs 12-Month DAPT for ACS Patients Who Underwent PCI Stratified by IVUS: IVUS-ACS and ULTIMATE-DAPT Trials; NCT03971500).

Intravascular imaging-guided percutaneous coronary intervention (PCI) has been shown to improve clinical outcomes in patients with complex coronary artery lesions compared with angiography-guided PCI. However, the prognostic impact of suboptimal findings on intravascular imaging such as stent underexpansion, malapposition, or dissection is unclear in the era of contemporary drug-eluting stents.

From RENOVATE-COMPLEX-PCI (Randomized Controlled Trial of Intravascular Imaging Guidance Versus Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention) which compared imaging-guided PCI with angiography-guided PCI in patients with complex lesions, post-PCI intravascular imaging findings, including minimum stent area (MSA), relative stent underexpansion (MSA≤80% of the average reference lumen area), malapposition, or dissection, were assessed in nonleft main target lesions. The primary end point was target lesion failure (TLF), a composite of cardiac death, target lesion-related myocardial infarction, target lesion revascularization, or definite stent thrombosis.

A total of 897 nonleft main lesions from 714 patients undergoing imaging-guided PCI were included. During a median follow-up duration of 2.1 years, the optimal cutoff value of MSA to predict the occurrence of TLF was 5.5 mm2, and MSA<5.5 mm2 was associated with a significantly higher risk of TLF than MSA≥5.5 mm2 (2.2% versus 4.8%; adjusted hazard ratio, 3.09 [95% CI, 1.01-9.50]; P=0.048). Compared with the reference group (MSA≥5.5 mm2 and no suboptimal findings), the subgroup of patients with MSA≥5.5 mm2 and post-PCI intravascular imaging findings of relative stent underexpansion, major malapposition, or major dissection was associated with a numerically increased risk of TLF (0.0% versus 3.2%; P=0.057). Compared with the same reference group, the subgroup of patients with MSA<5.5 mm2 and suboptimal post-PCI intravascular imaging findings was associated with a significantly increased risk of TLF (0.0% versus 4.7%; P=0.017).

After intravascular imaging-guided PCI with contemporary drug-eluting stents for nonleft main complex lesions, inadequate absolute stent expansion was independently associated with a higher risk of TLF. Suboptimal post-PCI intravascular imaging findings of relative stent underexpansion, major malapposition, and major dissection seem to contribute to the risk of TLF.

https://www.clinicaltrials.gov; Unique identifier: NCT03381872.

Optical coherence tomography (OCT) and intravascular ultrasound (IVUS) are adjunctive intracoronary imaging modalities used to optimize coronary stent implantation. However, the impact of OCT versus IVUS on clinical outcomes and periprocedural complications is unclear.

To perform a meta-analysis of all vetted randomized controlled trials comparing OCT-guided versus IVUS-guided percutaneous coronary intervention.

We queried MEDLINE, Cochrane Library, Scopus, and clinicalTrials.gov databases from their commencement to February 2024 for all randomized controlled trials that compared OCT-guided versus IVUS-guided percutaneous coronary interventions. The primary endpoint was major adverse periprocedural events (MAPE), a composite of stent thrombosis (ST), distal embolization (DE), and distal edge dissection (DED) at 30 days. The secondary endpoints included ST, DE, DED, major adverse cardiac events (MACE)-(a composite of cardiac death, target vessel myocardial infarction TVMI], and target vessel revascularization [TVR]), all-cause mortality, cardiac death, TVMI, TVR, and nonfatal stroke at 1 year. The odds ratio (OR) with a 95% confidence interval (CI) was analyzed using a random-effect model.

Seven randomized controlled trials were included in the analysis, and 4446 patients were enrolled. OCT was associated with lower MAPE (OR: 0.65, CI: 0.47-0.91, p = 0.01) compared to IVUS. ST, DE, and DED were similar between OCT and IVUS at 30 days. There were no significant differences in MACE (OR: 0.86, CI: 0.64-1.16, p = 0.32), all-cause mortality (OR: 0.83, CI: 0.42-1.66, p = 0.60), Cardiac death (OR:0.62, CI: 0.20-1.89, p = 0.40), TVMI (OR: 0.69, CI: 0.33-1.46, p = 0.33), TVR, (OR: 1.09, CI: 0.70-1.71, p = 0.70), and Nonfatal stroke (OR: 1.82, CI: 0.67-4.95, p = 0.24) 1 year following the index procedure.

Optical coherence tomographic-guided PCI was associated with lower MAPE, defined as a composite of ST, DE, and DED, compared to IVUS-guided PCI at 30 days of the index procedure. However, there was no difference in overall MACE, TVMI, TVR, and nonfatal stroke at 1 year.

Patients with end-stage renal disease (ESRD) are at a higher risk of cardiovascular diseases. Intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) using optical coherence tomography (OCT) or intravascular ultrasound (IVUS) has been shown to result in better clinical outcomes than angiography guidance. Nevertheless, the clinical outcomes of IVI-guided PCI in ESRD patients remain uncertain.

This study aimed to compare the clinical outcomes of OCT- and IVUS-guided PCIs in ESRD patients and to report the trend of IVI-guided PCI in Taiwan.

Patients with ESRD on maintenance dialysis, who underwent OCT- or IVUS-guided PCI from 2015 to 2021, were compared by propensity-score matching. The primary outcome was composite cardiovascular outcomes, including coronary revascularization, cardiovascular death, and acute myocardial infarction.

In 2021, IVI was used to guide PCIs in 27% (15,613 of 57,845) of general and 27.5% (1,754 of 6,387) of ESRD patients. Among 4,759 eligible ESRD patients, 443 and 4,316 patients underwent OCT- and IVUS-guided PCIs, respectively. After matching, the incidence of the primary outcome was comparable between the OCT and IVUS groups (42.1 [95% CI: 36.2-48.0] vs 47.6 [95% CI: 43.0-52.2] events per 100 person-years; HR: 0.88; 95% CI: 0.74-1.06). The results were similar for all components of the primary outcome and in subgroup analyses.

The number of PCI- and IVI-guided procedures has progressively increased in the past decade in Taiwan in both the general and ESRD populations. Among ESRD patients on maintenance dialysis, the clinical outcomes were comparable between OCT- and IVUS-guided PCI.

Stent underexpansion (SU) and aorto-ostial lesions (AOL) are challenging conditions commonly faced during clinical practice in the setting of percutaneous coronary interventions. Compared to other interventional settings, both SU and AOL are associated with an increased risk of immediate and late events following percutaneous coronary intervention. Several specific strategies including the systematic use of intracoronary imaging and dedicated techniques for lesions' preparation and calcium debulking have been described. This narrative review summarises the currently available options for the diagnosis and treatment of both SU and AOL, highlighting the potential benefits and limits of each technique in these specific settings.

Intravascular ultrasound (IVUS) in percutaneous coronary intervention (PCI) has transformed the management of complex higher risk-indicated patients (CHIPs), representing a pivotal advancement in high-risk procedure navigation. IVUS, complementing conventional angiography, provides unparalleled insights into lesion characteristics, plaque morphology, and vessel structure, enhancing the precision of stent placement and postprocedural care for CHIPs. The ongoing trials underscore the pivotal role of IVUS in optimizing procedural accuracy and improving clinical outcomes for high-risk patients, promising exciting new findings. However, notable gaps persist, encompassing the absence of standardized IVUS protocols, cost implications, and limited integration into routine practice. This study aims to address these gaps comprehensively by further delineating the influence of IVUS on patient outcomes, procedural success, and long-term prognostic indicators. This review aims to provide a clear overview of IVUS-guided PCI in CHIP, highlighting the significance of ongoing trials, identifying prevalent challenges, and outlining the objective of narrowing these gaps.

Despite the administration of timely reperfusion treatment, patients with acute myocardial infarction have a high mortality rate and poor prognosis. The potential impact of intraluminal imaging guidance, such as optical coherence tomography (OCT), on improving patient outcomes has yet to be conclusively studied. Therefore, we conducted a retrospective cohort study to compare OCT-guided primary percutaneous coronary intervention (PCI) versus angiography-guided for patients with ST-segment elevation myocardial infarction (STEMI).

This study enrolled 1396 patients with STEMI who underwent PCI, including 553 patients who underwent OCT-guided PCI and 843 patients who underwent angiography-guided PCI. The clinical outcome was a composite of cardiovascular death, myocardial infarction, admission due to heart failure, stroke, and unplanned revascularization at the 4-year follow-up.

The prevalence of major adverse cardiovascular events in OCT-guided group was not significantly lower compared to those without OCT guidance after adjustment (unadjusted hazard ratio (HR), 1.582; 95% confidence interval (CI), 1.300-1.924; p < 0.001; adjusted HR, 1.095; adjusted 95% CI, 0.883-1.358; p = 0.409). The prevalence of cardiovascular death was significantly lower in patients with OCT guidance compared to those without before and after adjustment (unadjusted HR, 3.303; 95% CI, 2.142-5.093; p < 0.001; adjusted HR, 2.025; adjusted 95% CI, 1.225-3.136; p = 0.004).

OCT-guided primary PCI used to treat STEMI was associated with reduced long-term cardiovascular death.

There are no clinical data on the efficacy of intravascular imaging-guided percutaneous coronary intervention (PCI) compared with angiography-guided PCI in patients with acute myocardial infarction (AMI) and cardiogenic shock. The current study sought to evaluate the impact of intravascular imaging-guided PCI in patients with AMI and cardiogenic shock.

Among a total of 28 732 patients from the nationwide pooled registry of KAMIR-NIH (November, 2011 to December, 2015) and KAMIR-V (January, 2016 to June, 2020), we selected a total of 1833 patients (6.4%) with AMI and cardiogenic shock who underwent PCI of the culprit vessel. The primary endpoint was major adverse cardiovascular events (MACE) at 1 year, a composite of cardiac death, myocardial infarction, repeat revascularization, and definite or probable stent thrombosis.

Among the study population, 375 patients (20.5%) underwent intravascular imaging-guided PCI and 1458 patients (79.5%) underwent angiography-guided PCI. Intravascular imaging-guided PCI was associated with a significantly lower risk of 1-year MACE than angiography-guided PCI (19.5% vs 28.2%; HR, 0.59; 95%CI, 0.45-0.77; P<.001), mainly driven by a lower risk of cardiac death (13.7% vs 24.0%; adjusted HR, 0.53; 95%CI, 0.39-0.72; P<.001). These results were consistent in propensity score matching (HR, 0.68; 95%CI, 0.46-0.99), inverse probability weighting (HR, 0.61; 95%CI, 0.45-0.83), and Bayesian analysis (Odds ratio, 0.66, 95% credible interval, 0.49-0.88).

In AMI patients with cardiogenic shock, intravascular imaging-guided PCI was associated with a lower risk of MACE at 1-year than angiography-guided PCI, mainly driven by the lower risk of cardiac death.

This study is to investigate the efficacy of stent implantation in patients with complex coronary artery disease (CAD) under intravascular ultrasound (IVUS) guidance and non-IVUS guidance.

We conducted a systematic search in PubMed, Web of Science, Cochran, and Embase for the articles of IVUS-guided and non-IVUS-guided stent implantation in patients with complex CAD and reported related outcomes. We included major adverse cardiovascular events (MACE), myocardial infarction (MI), cardiac death and other outcome indicators. Relative ratio (RR) and 95% confidence interval (CI) were used for statistical analysis.

A total of 5,173 subjects were included in 6 randomized control trials. The results showed that the incidence of MACE (RR: 0.63, 95% CI: 0.49-0.82, P < 0.001), cardiac death (RR: 0.61, 95% CI: 0.44-0.85, P = 0.004), target vessel revascularization (TVR) (P = 0.01), target lesion revascularization (TLR) (P = 0.03) and stent thrombosis (ST) (P = 0.002) in the experimental group (IVUS-guidance) was lower than that in the control group (non-IVUS-guidance). However, no statistical difference was observed between the both groups in the incidence of MI (P = 0.13) and all-cause death (P = 0.41).

Compared with the non-IVUS-guided group, IVUS-guided stent implantation may be more effective for patients with complex CAD.

PROSPERO [CRD42024531366].

Acute coronary syndrome (ACS) represents the most severe manifestation of coronary artery disease. Intravascular imaging, both intravascular ultrasound (IVUS) and optical coherence tomography (OCT), have played crucial roles for the impressive reduction in mortality of ACS. Intravascular imaging is useful for the detection of atherosclerotic mechanism (plaque rupture, calcified nodules, or plaque erosions) and for the evaluation of nonatherosclerotic and nonobstructive types of ACS. In addition, IVUS and OCT play a crucial role in the optimization of the PCI. The aim of the current review is to present the role of intravascular imaging in identifying the mechanisms of ACS and its prognostic role in future events, to review the current guidelines suggesting intravascular imaging use in ACS, to summarize its role in PCI in patients with ACS, and to compare IVUS and OCT.

Cardiovascular disease (CVD) is one of the most prevalent health threats globally. Traditional diagnostic methods for CVDs, including electrocardiography, ultrasound, and cardiac magnetic resonance imaging, have inherent limitations in real-time monitoring and high-resolution visualization of cardiovascular pathophysiology. In recent years, optical imaging technology has gained considerable attention as a non-invasive, high-resolution, real-time monitoring solution in the study and diagnosis of CVD. This review discusses the latest advancements, and applications of optical techniques in cardiac imaging. We compare the advantages of optical imaging over traditional modalities and especially scrutinize techniques such as optical coherence tomography, photoacoustic imaging, and fluorescence imaging. We summarize their investigations in atherosclerosis, myocardial infarction, and heart valve disease, etc. Additionally, we discuss challenges like deep-tissue imaging and high spatiotemporal resolution adjustment, and review existing solutions such as multimodal integration, artificial intelligence, and enhanced optical probes. This article aims to drive further development in optical imaging technologies to provide more precise and efficient tools for early diagnosis, pathological mechanism exploration, and treatment of CVD.

The left main coronary artery (LMCA) supplies over 70% of the myocardium, and significant LMCA disease is associated with high morbidity and mortality. With remarkable advances in percutaneous coronary intervention (PCI), including stent technology, antithrombotic agents, and evolving procedural techniques, PCI has become an important treatment option in clinical practice guidelines for the revascularization of LMCA disease. In contemporary clinical practice, a heart-team approach to shared decision-making, considering clinical/anatomic factors along with patient preferences, is emphasized for patients with significant LMCA disease requiring myocardial revascularization. Furthermore, recent progress in PCI procedures combined with intravascular imaging or functional guidance has resulted in significant improvements in PCI outcomes, especially for complex lesions, including LMCA disease. Nevertheless, owing to inherent anatomic complexities and frequent multivessel involvement, several unmet issues remain regarding the determination of the appropriate treatment approach for significant LMCA disease, for which further clinical research is required. This contemporary review article provides a comprehensive overview of left main PCI based on current guidelines and underlying trial data, addresses important unresolved diagnostic and therapeutic issues, and identifies future perspectives likely to advance progress in this field.

Intravascular imaging has become an integral part of the diagnostic and management strategies for intracoronary pathologies. In this White Paper we summarize current evidence and its implications on the use of intravascular imaging in interventional cardiology practice. The areas addressed are planning and optimization of percutaneous coronary intervention, management of stent failure, and evaluation of ambiguous coronary lesions and myocardial infarction with nonobstructive coronary disease. The findings presented followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system in an expert consensus process that involved a diverse writing group vetted by a review group. Expert consensus was achieved around 9 statements. Use of intravascular imaging in guiding percutaneous revascularization is supported by high-quality evidence, particularly for lesions with increased risk of recurrent events or stent failure. Specific considerations for intravascular imaging guidance of intervention in left main lesions, chronic occlusion lesions, and in patients at high risk of contrast nephropathy are explored. Use of intravascular imaging to identify pathologies associated with stent failure and guide repeat intervention, resolve ambiguities in lesion assessment, and establish diagnoses in patients who present with myocardial infarction with nonobstructive coronary disease is supported by moderate- to low-quality evidence. Each topic is accompanied by clinical pointers to aid the practicing interventional cardiologist in implementation of the White Paper findings. The findings presented in this White Paper will help to guide the use of intravascular imaging toward situations in which the balance of efficacy, safety, and cost are most optimal.

Optical coherence tomography (OCT) can identify high-risk plaques indicative of worsening prognosis in patients with acute coronary syndrome (ACS). However, manual OCT analysis has several limitations. In this study, we aim to construct a deep-learning model capable of automatically predicting ACS prognosis from patient OCT images following percutaneous coronary intervention (PCI).

Post-PCI OCT images from 418 patients with ACS were input into a deep-learning model comprising a convolutional neural network (CNN) and transformer. The primary endpoint was target vessel failure (TVF). Model performances were evaluated using Harrell's C-index and compared against conventional models based on human observation of quantitative (minimum lumen area, minimum stent area, average reference lumen area, stent expansion ratio, and lesion length) and qualitative (irregular protrusion, stent thrombus, malapposition, major stent edge dissection, and thin-cap fibroatheroma) factors. GradCAM activation maps were created after extracting attention layers by using the transformer architecture. A total of 60 patients experienced TVF during follow-up (median 961 days). The C-index for predicting TVF was 0.796 in the deep-learning model, which was significantly higher than that of the conventional model comprising only quantitative factors (C-index: 0.640) and comparable to that of the conventional model, including both quantitative and qualitative factors (C-index: 0.789). GradCAM heat maps revealed high activation corresponding to well-known high-risk OCT features.

The CNN and transformer-based deep-learning model enabled fully automatic prognostic prediction in patients with ACS, with a predictive ability comparable to a conventional survival model using manual human analysis.

The study was registered in the University Hospital Medical Information Network Clinical Trial Registry (UMIN000049237).

Percutaneous coronary intervention (PCI) has been most commonly guided by coronary angiography. However, to overcome the inherent limitations of conventional coronary angiography, there has been an increasing interest in the adjunctive tools of intracoronary imaging for PCI guidance. Recently, optical coherence tomography (OCT) has garnered substantial attention as a valid intravascular imaging modality for guiding PCI. However, despite the unparalleled high-resolution imaging capability of OCT, which offers detailed anatomical information on coronary lesion morphology and PCI optimisation, its broad application in routine PCI practice remains limited. Several factors may have curtailed the widespread adoption of OCT-guided PCI in daily practice, including the transitional challenge from intravascular ultrasound (IVUS), the experienced skill required for image acquisition and interpretation, the lack of a uniform algorithm for OCT-guided PCI optimisation, and the limited clinical evidence. Herein, we provide an in-depth review of OCT-guided PCI, involving the technical aspects, optimal strategies for OCT-guided PCI, and the wide application of OCT-guided PCI in various anatomical subsets. Special attention is given to the latest clinical evidence from recent randomised clinical trials with respect to OCT-guided PCI.

In acute myocardial infarction (AMI), the urgency of coronary revascularization through percutaneous coronary intervention (PCI) is paramount, offering notable advantages over pharmacologic treatment. However, the persistent risk of adverse events, including recurrent AMI and heart failure post-revascularization, underscores the necessity for enhanced strategies in managing coronary artery disease. Traditional angiography, while widely employed, presents significant limitations by providing only two-dimensional representations of complex three-dimensional vascular structures, hampering the accurate assessment of plaque characteristics and stenosis severity. Intravascular imaging, specifically optical coherence tomography (OCT), significantly addresses these limitations with superior spatial resolution compared to intravascular ultrasound (IVUS). Within the context of AMI, OCT serves dual purposes: as a diagnostic tool to accurately identify culprit lesions in ambiguous cases and as a guide for optimizing PCI procedures. Its capacity to differentiate between various mechanisms of acute coronary syndrome, such as plaque rupture and spontaneous coronary dissection, enhances its diagnostic potential. Furthermore, OCT facilitates precise lesion preparation, optimal stent sizing, and confirms stent deployment efficacy. Recent meta-analyses indicate that OCT-guided PCI markedly improves safety and efficacy in revascularization, subsequently decreasing the risks of mortality and complications. This review emphasizes the critical role of OCT in refining patient-specific therapeutic approaches, aligning with the principles of precision medicine to enhance clinical outcomes for individuals experiencing AMI.

The evolution of coronary intervention techniques and equipment has led to more sophisticated procedures for the treatment of highly complex lesions. However, as a result, the risk of complications has increased, which are mostly iatrogenic and often include equipment failure. Stent dislodgement warrants vigilance for the early diagnosis and a stepwise management approach is required to either expand or retrieve the lost stent. In the era of bioresorbable scaffolds that are not radiopaque, increased caution is required. Intravascular imaging may assist in detecting the lost scaffold in cases of no visibility fluoroscopically. Adequate lesion preparation is the key to minimizing the possibility of equipment loss; however, in the case that it occurs, commercially available and improvised devices and techniques may be applied.

Excessive stent strut protrusion in the distal left main (LM) from either the left anterior descending (LAD) or circumflex (Cx) artery following inadequate ostial stenting may complicate any later procedure involving the left coronary artery. In such case scenarios, intravascular ultrasound (IVUS) guidance provides accurate assessment of the ostial stent position and may facilitate subsequent management strategies and treatment.

We present a complex percutaneous coronary intervention (PCI) of LM bifurcation in a 49-year-old man following inadequate ostial Cx stenting that resulted in excessive stent protrusion in the distal LM segment, accompanied by a subsequent short 80-90% ostial LAD stenosis. Initially, IVUS was performed to confirm "floating struts" from a previous Cx ostial stenting and to ensure complete intraluminal placement of the wire within the stent leading to the Cx, precluding any side passage through the stent struts. Then, a second wire was inserted into the LAD through the most distal stent strut under live IVUS guidance. Further PCI was completed according to the principles of the double kissing mini-culotte technique. Final IVUS runs confirmed correct stent apposition and expansion in the LM, LAD and Cx segments.

In cases involving the treatment of "free-floating" struts in the distal LM artery, intravascular imaging is essential to ensure optimal PCI outcomes.

Despite the detailed imaging information provided by optical coherence tomography (OCT) during percutaneous coronary intervention (PCI), clinical benefits of this imaging technique in this setting remain uncertain. The aim of the OCCUPI trial was to compare the clinical benefits of OCT-guided versus angiography-guided PCI for complex lesions, assessed as the rate of major adverse cardiac events at 1 year.

This investigator-initiated, multicentre, randomised, open-label, superiority trial conducted at 20 hospitals in South Korea enrolled patients aged 19-85 years for whom PCI with drug-eluting stents was clinically indicated. After diagnostic angiography, clinical and angiographic findings were assessed to identify patients who met the criterion of having one or more complex lesions. Patients were randomly assigned 1:1 to receive PCI with OCT guidance (OCT-guidance group) or angiography guidance without OCT (angiography-guidance group). Web-response permuted-block randomisation (mixed blocks of four or six) was used at each participating site to allocate patients. The allocation sequence was computer-generated by an external programmer who was not involved in the rest of the trial. Outcome assessors were masked to group assignment. Patients, follow-up health-care providers, and data analysers were not masked. PCI was done according to conventional standard methods with everolimus-eluting stents. The primary endpoint was major adverse cardiac events (a composite of cardiac death, myocardial infarction, stent thrombosis, or ischaemia-driven target-vessel revascularisation), 1 year after PCI. The primary analysis was done in the intention-to-treat population. The margin used to establish superiority was 1·0 as a hazard ratio. This trial is registered with ClinicalTrials.gov (NCT03625908) and is completed.

Between Jan 9, 2019, and Sept 22, 2022, 1604 patients requiring PCI with drug-eluting stents for complex lesions were randomly assigned to receive either OCT-guided PCI (n=803) or angiography-guided PCI (n=801). 1290 (80%) of 1604 patients were male and 314 (20%) were female. The median age of patients at randomisation was 64 years (IQR 57-70). 1588 (99%) patients completed 1-year follow-up. The primary endpoint occurred in 37 (5%) of 803 patients in the OCT-guided PCI group and 59 (7%) of 801 patients in the angiography-guided PCI group (absolute difference -2·8% [95% CI -5·1 to -0·4]; hazard ratio 0·62 [95% CI 0·41 to 0·93]; p=0·023). Rates of stroke, bleeding events, and contrast-induced nephropathy were not significantly different across the two groups.

Among patients who required drug-eluting stent implantation for complex lesions, OCT guidance resulted in a lower incidence of major adverse cardiac events at 1 year compared with angiography guidance. These findings indicate the existence of a therapeutic benefit of OCT as an intravascular imaging technique for PCI guidance in patients with complex coronary lesions.

Abbott Vascular and Cardiovascular Research Center.

For the Korean translation of the abstract see Supplementary Materials section.