Intravascular ultrasound-guided treatment for angiographically indeterminate left main coronary artery disease: a long-term follow-up study

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 mm(2). Of the patients with angiographically indeterminate LMCAs, 83 (38.8%) had an MLA <7.5 mm(2), and 131 (61.2%) an MLA > or =7.5 mm(2). Left main coronary artery revascularization was performed in 85.5% (71 of 83) of patients with an MLA <7.5 mm(2) and deferred in 86.9% (114 of 131) of patients with an MLA > or =7.5 mm(2). 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 mm(2) who underwent revascularization and those with an MLA > or =7.5 mm(2) deferred for revascularization (p = 0.28). Based on outcome, the best cut-off MLA by receiver operating characteristic was 9.6 mm(2). 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 > or =7.5 mm(2) appears to be safe.