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J Am Coll Cardiol, 2005; 45:204-211, doi:10.1016/j.jacc.2004.09.066
© 2005 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY

Intravascular ultrasound-guided treatment for angiographically indeterminate left main coronary artery disease

A long-term follow-up study

Amir-Ali Fassa, MD, Kenji Wagatsuma, MD, Stuart T. Higano, MD, Verghese Mathew, MD, Gregory W. Barsness, MD, Ryan J. Lennon, MS, David R. Holmes, Jr, MD and Amir Lerman, MD*

Center of Coronary Physiology and Imaging, Cardiac Catheterization Laboratory, Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota

Manuscript received May 27, 2004; revised manuscript received September 24, 2004, accepted September 28, 2004.

* Reprint requests and correspondence: Dr. Amir Lerman, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905 (Email: lerman.amir{at}mayo.edu).

OBJECTIVES: The purpose of this study was to evaluate the efficacy of an intravascular ultrasound (IVUS)-guided strategy for patients with angiographically indeterminate left main coronary artery (LMCA) disease.

BACKGROUND: The assessment of LMCA lesions using coronary angiography is often challenging; IVUS provides useful information for assessment of coronary disease.

METHODS: Intravascular ultrasound was performed on 121 patients with angiographically normal LMCAs to determine the lower range of normal minimum lumen area (MLA), defined as the mean – 2 SD. We conducted IVUS studies on 214 patients with angiographically indeterminate LMCA lesions, and deferral of revascularization was recommended when the MLA was larger than this predetermined value.

RESULTS: The lower range of normal LMCA MLA was 7.5 mm2. Of the patients with angiographically indeterminate LMCAs, 83 (38.8%) had an MLA <7.5 mm2, and 131 (61.2%) an MLA ≥7.5 mm2. Left main coronary artery revascularization was performed in 85.5% (71 of 83) of patients with an MLA <7.5 mm2 and deferred in 86.9% (114 of 131) of patients with an MLA ≥7.5 mm2. Long-term follow-up (mean 3.3 ± 2.0 years) showed no significant difference in major adverse cardiac events (target vessel revascularization, acute myocardial infarction, and death) between patients with an MLA <7.5 mm2 who underwent revascularization and those with an MLA ≥7.5 mm2 deferred for revascularization (p = 0.28). Based on outcome, the best cut-off MLA by receiver operating characteristic was 9.6 mm2. Multivariate predictors of cardiac events were age, smoking, and number of non-LMCA vessels diseased.

CONCLUSIONS: Intravascular ultrasound is an accurate method to assess angiographically indeterminate lesions of the LMCA. Furthermore, deferring revascularization for patients with a minimum lumen area ≥7.5 mm2 appears to be safe.

Abbreviations and Acronyms
  CABG = coronary artery bypass graft
  CSA = cross-sectional area
  EEM = external elastic membrane
  IVUS = intravascular ultrasound
  LMCA = left main coronary artery
  MACE = major adverse cardiac events
  MLA = minimum lumen area
  MLD = minimum lumen diameter
  PCI = percutaneous coronary intervention
  P+M = plaque plus media




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