What is the reason for and aim of the publication?
Percutaneous coronary intervention (PCI) for left main disease is technically complex and clinically high-risk. Intracoronary imaging (ICI) guidance for left main PCI has gained the highest guideline recommendation for both acute and chronic coronary syndrome patients. Despite this endorsement, our consensus statement recognises the needs of the interventional community in supporting the effective adoption of ICI to guide and optimise left main PCI.
What are the most important take-home messages?
- Effective intracoronary imaging guidance of LM PCI requires engagement in ICI-based pre-stenting procedural planning.
- Metrics of optimal stent expansion are important criteria for acute-PCI success.
- ICI evaluation of a LM-PCI result should be the last procedural step to confirm optimisation and exclude the presence of unintended stent deformation.
Central illustration: Pre and post-PCI criteria for the effective guidance of left main stenting using intracoronary imaging.
What are challenges in practical implementation – and possible solutions?
Rates of ICI use in many regions are very limited, and, associated with this, operator confidence, combined with remuneration/health economics, remain barriers to implementation of ICI-guidance for LM-PCI. The guideline endorsement, specifically for ICI-guided LM-PCI, may lead to providers funding ICI use and in some areas, ICI-guidance has been included as a quality metric.
Which issues still need to be tackled, that are not yet addressed by the paper?
Education for PCI operators and allied health professionals to increase confidence in ICI interpretation and a greater focus on actionable imaging are required. These issues cannot be overcome through a consensus statement but this document importantly outlines best practice, identifying expectations for maximising the potential of ICI-guidance in complex PCI.
What further developments on the topic are emerging?
Technological developments continue to provide support for physicians through automated tissue characterisation, angiographic co-registration, physiological surrogates and vessel/stent measurements. Combining imaging modalities, harnessing ultrasound, optics and spectroscopy will further assist physicians in characterising lesion morphology and enhancing decision-making.
Intracoronary imaging for left main percutaneous coronary intervention
Johnson TW, Gonzalo N, de la Torre Hernandez JM, et al. Intracoronary imaging for left main percutaneous coronary intervention: a clinical consensus statement of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC and the European Bifurcation Club (EBC). Eur Heart J. Published online May 15, 2026. https://doi.org/10.1093/eurheartj/ehag353
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