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OCT-guided PCI shows improved outcomes vs. angiography alone in cohort study
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In a cohort study based on the Pan-London PCI registry, patients who underwent OCT-guided PCI had improved procedural outcomes, in-hospital MACE and long-term survival compared with patients who underwent standard angiography-guided PCI, and similar outcomes compared with IVUS-guided PCI.
Daniel A. Jones, MD, PhD, from the department of cardiology at Barts Heart Centre, Barts Health NHS Trust, London, and colleagues performed the cohort study to evaluate the effect of OCT-guided PCI on long-term survival. In total, 123,764 patients who underwent PCI at National Health Service hospitals in London from 2005 to 2015 were included in the Pan-London (United Kingdom) PCI registry. After excluding patients with acute STEMI and those who underwent pressure wire-guided PCI, the cohort examined in the current study totaled 87,166 patients.
“OCT is an established intravascular imaging method that provides rapid acquisition of high-resolution images capable of assessing lumen dimensions and identifying thrombus, lipid, calcium, dissections, plaque prolapse, stent malapposition and under-expansion. This superior spatial resolution of OCT could translate into meaningful clinical benefits and recent studies have suggested potential benefits using OCT guidance for PCI with improved outcomes in the short term. However, to date no data exist about the effect of OCT on hard clinical endpoints in the long term,” Jones and colleagues wrote in JACC: Cardiovascular Interventions.
In this cohort, PCI guided by angiography was performed in 86.1% of patients, IVUS in 12.6% and OCT in 1.3%.
The rate of OCT use increased from 2005 to 2015 (P < .0001), and the researchers noted a similar increase in the use of IVUS (P < .0001). However, use of both devices varied significantly across the centers included in this cohort study.
“One of the main findings stemming from this large observational study … is that the rate of intravascular imaging in daily practice remains low,” Carlo Di Mario, MD, PhD, and Alessio Mattesini, MD, both from the division of structural interventional cardiology at Careggi University Hospital in Florence, Italy, wrote in an accompanying editorial.
However, they wrote, “There is a lower overall rate of use of intravascular imaging globally than in the nine participating cardiac centers across London, with the exception of Japan, Korea and, in part, the United States.”
In other findings, OCT- or IVUS-guided PCI was more common among patients who were younger. OCT guidance was also more common in those who underwent elective procedures and those who presented with a history of MI and previous PCI. The angiography-guided PCI group had the shortest mean stent length and the OCT-guided group had the longest mean stent length. In-hospital MACE was lower with OCT guidance and IVUS guidance compared with angiography.
The primary endpoint of this cohort study was all-cause mortality at a median follow-up of 4.8 years. The rate of mortality was 7.7% in the OCT-guided group vs. 12.2% in the IVUS-guided group and 15.7% in the angiography-guided group (P < .0001). However, differences in unadjusted mortality with OCT vs. IVUS were nonsignificant after adjustment (HR = 0.85; 95% CI, 0.63-1.34). Mortality differed among patients who underwent elective procedures and those with ACS. The overall mortality difference at follow-up persisted after the researchers performed multivariate Cox analysis (HR = 0.48; 95% CI, 0.26-0.81) and propensity matching (HR = 0.39; 95% CI, 0.21-0.77), with no difference in matched OCT and IVUS cohorts (HR = 0.88; 95% CI, 0.61-1.38).
“The findings of our study provide for the first time an answer to the debate about the role of invasive imaging in guiding PCI, showing that both IVUS and OCT outperform stand-alone angiography and are equally effective in improving outcomes,” Jones and colleagues wrote.
The researchers and the editorial authors called for further research on OCT guidance during PCI, particularly to identify groups of patients and anatomic settings that may yield the greatest prognostic benefit.
“In the last 3 decades, IVUS and, more recently, OCT have been increasingly used to guide PCI. Although there are randomized trials, registries and meta-analyses suggesting better outcomes using IVUS to guide PCI, data on the clinical impact of OCT are still missing,” Di Mario and Mattesini wrote.
One such trial that may provide further insight is ILUMIEN IV, a multicenter, randomized trial that “appears sufficiently large to address outcome differences and establish whether the claimed superiority of OCT to angiography is confirmed,” Di Mario and Mattesini wrote. In addition, the ongoing, randomized OCTOBER study will assess whether systematic OCT-guided PCI of complex bifurcation lesions yields superior clinical outcomes at 2 years vs. standard revascularization, including liberal use of IVUS, according to Di Mario and Mattesini. – by Katie Kalvaitis
Disclosures: Di Mario, Jones and Mattesini report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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