Author + information
- Francesco Prati, MD∗ (, )
- Enrico Romagnoli, MD and
- Laura Gatto, MD
- ↵∗Interventional Cardiology, San Giovanni Addolorata Hospital and CLI Foundation, Via Amba Aradam, 8, Rome 00184, Italy
The main advantage of optical coherence tomography (OCT) resides in its ability to identify issues that may be missed by intravascular ultrasound (IVUS); however, OCT may provide operators with an excess of information that may lead to an overreaction, in an effort to correct innocent but ominous-looking anatomic issues.
The CLI-OPCI (Centro per la Lotta contro l’Infarto-Optimisation of Percutaneous Coronary Intervention) II study (1) was specifically designed to answer these crucial questions in “everyday” practice and therefore included a heterogeneous population, with demographic, clinical, and procedural differences. Importantly, the CLI-OPCI project was conceived years ago to gather OCT data from more centers, year by year, with the goal of refining our understanding of OCT findings. The original metrics we set up in CLI-OPCI I (2) did work well; however, their refinement over time was a key process.
Dr. Lee and colleagues suggest the application of a single criterion: the presence of an in-stent minimal lumen area (MLA) greater than the distal reference lumen area (3). We do appreciate their effort to standardize and simplify procedures, but we doubt that this is the solution to be pursued with imaging modalities for the following reasons.
First, in the CLI-OPCI II study, the problems at the references were by far the most relevant, being related to a risk of major adverse cardiac events (MACE) that was 8.1 times higher than for control subjects (Figure 1B). The stent percentage of underexpansion suggested by Dr. Lee and colleagues (MLA <70% of reference lumen areas) would guarantee a much inferior clinical benefit. On the basis of our data, MACE were found in 22.7% of cases when absolute values were applied (in-stent MLA <4.5 mm2) versus 19.5% of cases using the percentage of underexpansion. Furthermore, other IVUS studies (4) have indicated that the absolute MLA value is more efficient than the percentage of underexpansion in predicting the risk of cardiovascular events.
Second, the approach we suggest is rather simple and fast, because readers can rely on the automated analysis shown in the lumen profile view (St. Jude Medical, St. Paul, Minnesota) (Figure 1A). Based on the approach suggested by the CLI-OPCI II data (1), interventional cardiologists have to proceed with 2 simple steps: 1) make sure that the lumen area inside the stent and references is larger than 4.5 mm2; and 2) exclude significant dissections with a width larger than 0.2 mm at the distal edge. Let’s use OCT for what it is worth rather than as an alternative for IVUS.
Few things are better than a good friend, but for real fun, you need a few more.
Please note: Dr. Prati is a consultant for St. Jude Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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