Integrating Intracoronary Imaging into PCI Workflow and Catheterization Laboratory Culture

Intravascular Imaging-Guided Versus Angiography-Guided Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background/Objectives: Despite the potential benefits, intravascular imaging for guiding percutaneous coronary intervention (PCI) remains underutilized. Recent trials have provided new data, prompting a need for updated insights. This study aimed to perform a comprehensive meta-analysis to compare the clinical outcomes of intravascular imaging-guided PCI versus angiography-guided PCI, thereby evaluating the relative effectiveness of these two guidance strategies in improving patient outcomes. Methods: PubMed, Cochrane Library, Embase and Clinicaltrials.gov databases were systematically searched from inception till 25 November 2024. Randomized clinical trials (RCTs) comparing intravascular imaging with coronary angiography in patients undergoing complex PCI were included. Statistical analysis was conducted using a random effects model to calculate pooled risk ratios with 95% confidence intervals (CI). Results: In this meta-analysis of 21 studies involving 18,043 patients, intravascular image-guided PCI significantly reduced the risk of all-cause mortality by 24%, cardiac mortality by 63%, MACE by 35%, target vessel myocardial infarction by 32%, stent thrombosis by 42%, target vessel revascularization by 45%, target lesion revascularization by 34% and myocardial infarction by 22% compared to angiography-guided PCI. There was no significant difference in bleeding events. Conclusions: Intravascular imaging significantly reduces cardiac events, all-cause mortality and revascularization rates in PCI patients. These findings support its broader adoption and potential updates to clinical guidelines.

Complex high-risk indicated PCI (CHIP-PCI): is it safe to let fellows-in-training perform it as primary operators?

BACKGROUND

Training in complex high-risk indicated percutaneous coronary intervention (CHIP-PCI) has frequently been reserved for established operators (consultants/attending) with trainees (fellows-in-training or FIT) being often discouraged from carrying out such procedures as a primary operator due to their high-risk nature. Whether the outcomes of these cases differ if the primary operator is a supervised FIT compared with a consultant is unknown.

METHODS

Using multicentre PCI data from three cardiac centres in South Wales, UK (2018-2022), we identified 2295 CHIP-PCI cases with a UK-BCIS CHIP Score of 3 or more. These were then divided by primary operator status (supervised FIT vs consultant); the primary outcome was in-hospital major adverse cardiac events (IH-MACCE). Multivariate logistic models were developed to adjust for differences in baseline and procedural characteristics.

RESULTS

The primary operator in 838 (36%) of the PCIs was a supervised FIT. Baseline and procedural characteristics had lower complexity in CHIP-PCI cases carried out by supervised FIT vs consultant. In a multivariate-adjusted model, supervised FIT procedures were associated with lower odds of concurrent valve disease (OR 0.45, 95% CI: 0.29 to 0.69), dual access (OR 0.58, 95% CI: 0.41 to 0.83), cutting/scoring balloons (OR 0.59, 95% CI: 0.44 to 0.79) and rotational atherectomy (OR 0.60, 95% CI: 0.42 to 0.87). After adjusting for all variables, however, there was no difference in the primary outcome (OR 0.72, 95% 0.34 to 1.51) or any secondary outcomes. Sensitivity analyses restricted to patients with higher CHIP Scores (4+ and 5+) showed comparable IH-MACCE.

CONCLUSIONS

Training FIT as primary operators in CHIP-PCI appears to be feasible and safe and can be delivered within the standard training programme. The comparable outcomes are likely driven by the two-operator 'buddy' effect that a FIT supervised by a consultant benefits from.

Image-guided percutaneous revascularization of the coronary arteries

The European Society of Cardiology recently updated guidelines on the management of chronic coronary syndromes upgrading the use of intracoronary imaging for complex percutaneous coronary interventions (PCI) to a class 1A recommendation. It is essential that the interventional community appreciate the additive value of intracoronary imaging over angiography alone-not only to obtain optimal acute PCI results but also to improve longer-term cardiovascular outcomes. The purpose of this manuscript is to review the latest evidence that informed the recent guideline recommendations and expand on the specific role of the different imaging modalities before, during, and after PCI.

Does artificial intelligence enhance physician interpretation of optical coherence tomography: insights from eye tracking

Background and objectives

The adoption of optical coherence tomography (OCT) in percutaneous coronary intervention (PCI) is limited by need for real-time image interpretation expertise. Artificial intelligence (AI)-assisted Ultreon™ 2.0 software could address this barrier. We used eye tracking to understand how these software changes impact viewing efficiency and accuracy.

Methods

Eighteen interventional cardiologists and fellows at McMaster University, Canada, were included in the study and categorized as experienced or inexperienced based on lifetime OCT use. They were tasked with reviewing OCT images from both Ultreon™ 2.0 and AptiVue™ software platforms while their eye movements were recorded. Key metrics, such as time to first fixation on the area of interest, total task time, dwell time (time spent on the area of interest as a proportion of total task time), and interpretation accuracy, were evaluated using a mixed multivariate model.

Results

Physicians exhibited improved viewing efficiency with Ultreon™ 2.0, characterized by reduced time to first fixation (Ultreon™ 0.9 s vs. AptiVue™ 1.6 s, p = 0.007), reduced total task time (Ultreon™ 10.2 s vs. AptiVue™ 12.6 s, p = 0.006), and increased dwell time in the area of interest (Ultreon™ 58% vs. AptiVue™ 41%, p < 0.001). These effects were similar for experienced and inexperienced physicians. Accuracy of OCT image interpretation was preserved in both groups, with experienced physicians outperforming inexperienced physicians.

Discussion

Our study demonstrated that AI-enabled Ultreon™ 2.0 software can streamline the image interpretation process and improve viewing efficiency for both inexperienced and experienced physicians. Enhanced viewing efficiency implies reduced cognitive load potentially reducing the barriers for OCT adoption in PCI decision-making.

Association Between Intracoronary Imaging During PCI and Clinical Outcomes in a Real-World US Medicare Population

Background

Use of intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during percutaneous coronary intervention (PCI) is endorsed by society guidelines, but US data on real-world outcomes are lacking.

Methods

Medicare claims data were identified for inpatient PCIs performed October 2015 to March 2020, with IVUS/OCT captured by ICD-10-PCS codes. Three-way propensity score matching (angio vs IVUS vs OCT) on baseline and procedural characteristics was performed. Major adverse cardiovascular events (MACE), a composite of death, myocardial infarction (MI), or repeat revascularization, was evaluated through 3 years, with a 30-day blanking window after index PCI to exclude staged procedures.

Results

Of the 502,821 PCI procedures, 463,201 (92%) were guided by angiography alone, with IVUS or OCT used in 37,908 (7.5%) and 1712 (0.3%), respectively. After propensity matching, compared with angiography, the risk of major adverse cardiovascular event was similar for IVUS (hazard ratio [HR], 0.97; 95% CI, 0.91-1.03; P = .285) but lower for OCT (HR, 0.85; 95% CI, 0.77-0.94; P = .001). A similar trend was observed in clinically relevant subgroups. Compared with angiography alone, the risk of MI or repeat revascularization was lower with OCT (HR, 0.86; 95% CI, 0.76-0.97; P = .015), and the risk of MI alone was lower with IVUS (HR, 0.90; 95% CI, 0.82-0.99; P = .038).

Conclusions

In a real-world US cohort, IVUS and OCT were used infrequently during PCI. Compared with angiography alone, use of intracoronary imaging during index PCI was associated with lower rates of clinical events through 3 years.