The Official Journal of EuroPCR and the European Association of Percutaneous Coronary Interventions (EAPCI)

Intravascular ultrasound to guide left main stem intervention: a sub-study of the NOBLE trial

DOI: 10.4244/EIJ-D-19-01003

1. Department of Cardiology, Glenfield Hospital, Leicester, UK.
2. Department of Cardiology, Royal Victoria Hospital, Belfast, Northern Ireland, UK.
3. Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus, Denmark.
4. Department of Cardiology, Oulu University Hospital, Oulu, Finland.
5. Department of Cardiology, Örebro University Hospital Örebro, Sweden.
6. Sussex Cardiac Centre, Brighton and Sussex University Hospital, Brighton, UK.
7. Heart Center, Kuopio University Hospital, Kuopio, Finland.
8. Craigavon Cardiac Centre, Craigavon, Northern Ireland, UK.
9. Latvia Centre of Cardiology, Paul Stradins Clinical Hospital, Riga.
10. Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
11. Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
12. Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus, Denmark, Denmark
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Aims—We investigated the association between the use and findings of IVUS with clinical outcomes in the PCI arm of a randomised trial of LMS PCI.

Methods and Results—The NOBLE trial randomised patients with LMS disease to treatment by PCI or CABG. Of 603 patients treated by PCI, 435(72%) underwent post-PCI IVUS assessment of which 224 were analysed in a core-laboratory. At 5 years, the composite of MACCE were 18.9% if post-PCI IVUS was performed vs. 25.0% if not (p=0.45, after adjustment).  Overall repeat revascularization was not reduced (10.6% vs. 16.5%, p=0.11), however LMS TLR was (5.1% vs. 11.6%, p=0.01) if IVUS was used. For comparison of stent expansion, LMS MSA was split into tertiles. We found no significant difference in MACCE, death, myocardial infarction or stent thrombosis between tertiles. There was a significant difference between the lower and upper tertiles for repeat revascularisation (17.6% vs. 5.2%, p=0.02) and LMS TLR (12.2% vs. 0%, p=0.002).

Conclusions—Post PCI IVUS assessment and adequate stent expansion are not associated with reduced MACCE, however there is an association with reduced LMS TLR. Use of intra-coronary imaging to prevent stent under-expansion in LMS PCI is likely to improve outcomes.

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