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Impact of Operator Experience and IVUS-Guided PCI
Quick Takes
- IVUS-guided PCI significantly reduced the long-term risk of cardiac death or target-vessel MI compared with angiography-guided PCI in patients with complex CAD.
- Of note, the IVUS-guided PCI group had lower proportions of cardiovascular risk factors and ACS.
- More robust high-quality randomized data are indicated to validate benefits of IVUS-guided PCI and further encourage its use.
Study Questions:
What is the influence of operator experience on lesion complexity, long-term clinical outcomes, and the interactions of intravascular ultrasound (IVUS) guidance in patients undergoing complex percutaneous coronary intervention (PCI)?
Methods:
The investigators recruited a total of 6,005 patients who underwent PCI with drug-eluting stents for complex lesions from the institutional registry of Samsung Medical Center. The study population was stratified by use of IVUS and operator experience (less experienced operator [lifetime independent experience with PCI ≤5 years] vs. experienced operator). The primary endpoint was a composite of cardiac death or target-vessel myocardial infarction (TVMI) up to 10 years. The cumulative incidence of clinical events was presented as a Kaplan-Meier estimate, and the significance level was assessed with a log-rank test.
Results:
Compared to less experienced operators, experienced operators used IVUS more frequently (29.6% [1,128/3,805] vs. 24.8% [546/2,200], p < 0.001) and achieved a lower risk of cardiac death or TVMI (experienced vs. less experienced, adjusted hazard ratio [aHR], 0.779; 95% confidence interval [CI], 0.663-0.915; p = 0.002). IVUS use was associated with a significantly lower risk of cardiac death or TVMI than angiography alone for less experienced operators (23.5% vs. 11.4%; aHR, 0.477; 95% CI, 0.337-0.673; p < 0.001) as well as experienced operators (18.0% vs. 13.5%; aHR, 0.747; 95% CI, 0.559-0.998; p = 0.048). There were significant interactions for the risk of cardiac death or TVMI between IVUS use and operator experience (p = 0.037).
Conclusions:
The authors report that PCI by experienced operators and use of IVUS during complex PCI were independently associated with lower long-term risks of cardiac death or TVMI.
Perspective:
This single-center, retrospective, observational study reports that IVUS-guided PCI significantly reduced the long-term risk of cardiac death or TVMI compared with angiography-guided PCI in patients with complex coronary artery disease (CAD), regardless of operator experience. Furthermore, the benefits of IVUS guidance were more apparent in patients who were treated by less experienced operators than in those who were treated by experienced operators. Of note, the IVUS-guided PCI group had lower proportions of cardiovascular risk factors and acute coronary syndrome (ACS) and patients who underwent PCI from experienced operators were less likely to undergo urgent procedures. More robust high-quality randomized data are indicated to validate benefits of IVUS-guided PCI and further encourage its use.
Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Echocardiography/Ultrasound, Nuclear Imaging
Keywords: Acute Coronary Syndrome, Angiography, Coronary Artery Disease, Drug-Eluting Stents, Myocardial Infarction, Myocardial Ischemia, Percutaneous Coronary Intervention, Risk Factors, Secondary Prevention, Ultrasonography, Interventional
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