Optical Coherence Tomography–Guided Percutaneous Coronary Intervention in ST-Segment–Elevation Myocardial Infarction

The culprit lesion in ST-segment–elevation myocardial infarction (STEMI) is usually occluded, thrombotic, and subject to vasospasm. These factors can make adequate sizing and deployment of stents in STEMI more challenging than in other clinical settings. Patients with STEMI are at high risk of adverse cardiac outcomes that may be improved with more complete stent apposition and expansion. These factors suggest that intravascular imaging may be beneficial in primary percutaneous coronary intervention (PCI). However, previous observational studies using intravascular ultrasound in STEMI have shown conflicting results. Optical coherence tomography (OCT) is a newer intravascular imaging modality that has greater resolution than intravascular ultrasound. OCT can be performed rapidly and can Background—Patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment–elevation myocardial infarction are at increased risk for adverse events. It is unclear if image guidance by optical coherence tomography (OCT) can improve outcomes in these patients. We compared OCT-guided versus angiography-guided primary PCI for STsegment–elevation myocardial infarction among patients in the Thrombectomy Versus PCI Alone (TOTAL) trial. Methods and Results—Among 10 732 patients enrolled in the TOTAL trial, OCT was used for PCI guidance as a part of a prospective substudy in 214 patients. Using 2:1 propensity matching, we identified 428 patients in the trial who had PCI performed with angiography guidance alone. The primary outcome was a composite of cardiovascular death, myocardial infarction, stent thrombosis, and target-vessel revascularization at 1 year. Secondary outcomes included final in-stent angiographic minimum lumen diameter, procedure time, and contrast dose. The final in-stent angiographic minimum lumen diameter was 2.99±0.48 mm in the OCT-guided group versus 2.79±0.47 mm in the angiography-guided group (P<0.0001). OCTand angiography-guided PCI had a median (interquartile range) procedure time of 58 (47, 71) minute versus 38 (28, 52) minute (P<0.0001) and total contrast dose of 239.7±81.1 mL versus 193.3±78.6 mL (P<0.0001). The primary outcome was observed in 7.5% of the OCT-guided group versus 9.8% of the angiography-guided group (hazard ratio, 0.76; 95% confidence interval, 0.43–1.34; P=0.34). Conclusions—OCT-guided primary PCI for ST-segment–elevation myocardial infarction was associated with a larger final in-stent minimum lumen diameter. There was no significant difference in clinical outcomes at 1 year; however, the study was underpowered to detect a treatment effect. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01149044. (Circ Cardiovasc Interv. 2016;9:e003414. DOI: 10.1161/CIRCINTERVENTIONS.115.003414.)