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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

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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