Decision-Making During Percutaneous Coronary Intervention Guided by Optical Coherence Tomography: Insights From the LightLab Initiative

Abstract

Background: Use of intracoronary imaging is associated with improved outcomes in patients undergoing percutaneous coronary intervention (PCI). Yet, the impact of intracoronary imaging on real-time physician decision-making during PCI is not fully known.

Methods: The LightLab Initiative is a multicenter, prospective, observational study designed to characterize the use of a standardized optical coherence tomography (OCT) workflow during PCI. Participating physicians performed pre-PCI and post-PCI OCT in accordance with this workflow and operator assessments of lesion characteristics and treatment plan were recorded for each lesion based on angiography alone and following OCT. Physicians were categorized as having low (n=15), intermediate (n=13), or high (n=14) OCT use in the year preceding participation.

Results: Among 925 patients with 1328 lesions undergoing PCI, the prescribed OCT workflow was followed in 773 (84%) of patients with 836 lesions. Operator lesion assessment and decision-making during PCI changed with OCT use in 86% (721/836) of lesions. Pre-PCI OCT use changed operator decision-making in 80% of lesions, including lesion assessment (45%), vessel preparation strategy (27%), stent diameter (37%), and stent length (36%). Post-PCI OCT changed stent optimization decision-making in 31% of lesions. These findings were consistent across strata of physician prior OCT experience.

Conclusions: A standardized OCT workflow impacted PCI decision-making in 86% of lesions, with a predominant effect on pre-PCI lesion assessment and planning of treatment strategy. This finding was consistent regardless of operator experience level and provides insight into mechanisms by which intravascular imaging might improve PCI outcomes.

Keywords: decision-making; intravascular imaging; optical coherence tomography; percutaneous coronary intervention; planning.

Figure 1.

LightLab study phases and MLD MAX workflow. MLD MAX is a prescriptive optical coherence tomography (OCT) workflow that guides treatment decisions during percutaneous coronary intervention (PCI). The workflow encompasses assessment of lesion morphology, length, and diameter from the pre-PCI OCT pullback, and medial dissection, stent apposition, and stent expansion from the post-PCI OCT pullback (acronym MLD MAX).

Figure 2.

Study flowchart: LightLab Initiative decision-making phase. CABG indicates coronary artery bypass grafting; IVUS, intravascular ultrasound; OCT, optical coherence tomography; and PCI, percutaneous coronary intervention.

Figure 3.

Impact of optical coherence tomography (OCT) workflow guidance on changes in lesion assessment and percutaneous coronary intervention (PCI) decision-making. A, Bar chart indicates % of lesions studied where OCT altered initial physician decision-making based on angiographic assessment; bars are colored according to a definitive change in assessment (dark blue bars: ie, lesion morphology, treatment strategy and presence of stent edge dissections, major malapposition or stent underexpansion), or where strategy was escalated (mid blue bars: ie, more aggressive vessel preparation, increase in stent number/length/diameter) or de-escalated (gray bars: that is, less aggressive/no vessel preparation, reduction in stent number/length/diameter). The % change in strategy is indicated by the accompanying legend. Cumulative impact of changes in decision-making per lesion are demonstrated by the red trend line and indicate an overall impact of OCT on changes from angiographic decision-making in 86% of the cases. The bars are grouped by pre-PCI impact (cumulative 80% lesions) and post-PCI impact (cumulative 31% lesions). Note: additional factors were assessed within the diagnostic category and not shown on graph: lesion type per American College of Cardiology/American Heart Association guidelines (21%) and decision to treat percutaneously (2%). B, Focused impact of OCT on procedural decision-making excluding effects on lesion assessment.

Figure 4.

Impact of optical coherence tomography (OCT) guidance on changes in vessel preparation modality categorized by predominant lesion morphology. Data indicate frequency of change in vessel preparation strategy categorized by predominant lesion morphology assessed by OCT. Vessel calcification identified on OCT drove most changes in strategy, with increased use of specialty balloons or atherectomy.

Figure 5.

Prior physician optical coherence tomography (OCT) experience and changes in decision-making for pre- and post-percutaneous coronary intervention (PCI) OCT imaging. Bar chart demonstrates frequency of change to angiographic decision-making/lesion assessment after pre-PCI and post-PCI imaging with OCT, and demonstrates the lack of impact of self-reported prior physician OCT experience (see Figure 2) in reducing utility of OCT imaging.