Key result
IVUS-guided PCI in the OPTIMAL trial may have shown a neutral outcome due to an expert-center ceiling effect across 28 high-volume centers (>600 PCIs/year) with 96.0% post-dilation in the control arm.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“A central argument is that both neutral studies were conducted in high-volume centers with very experienced IVUS operators. It is therefore plausible that some of the IVUS expertise acquired over years was “carried over” into the angiography-guided arm. In such a setting, the comparison is no longer between “optimal imaging” and “ordinary angiography,” but rather between imaging and an already “IVUS-calibrated” form of angiography. For this reason, the neutral results should not be uncritically extrapolated to routine care.”
“Despite strong endorsement from practice guidelines to use IVUS guidance for ULMCAD PCI, the OPTIMAL trial did not show superiority of an IVUS-guided PCI approach over the control arm of angiography-guided PCI. Estimated event rates in the trial were sufficient, anatomical complexity scores were high (mean SYNTAX score, 29.7), and 49.2% of patients presented with acute coronary syndrome. However, both groups also had very high rates of both post-dilatation (97.0% IVUS group; 96.0% angiography group) and proximal optimization (89.6% IVUS group; 85.1% angiography group).”
This letter to the editor highlights that the neutral outcome of the OPTIMAL trial of IVUS-guided left main PCI may be influenced by an expert-center ceiling effect across the 28 high-volume participating centers.
To the Editor: Regarding the OPTIMAL (Optimization of Left Main PCI with Intravascular Ultrasound) trial by Testa et al. (June 11 issue), 1 we worry that a simplistic reading of the neutral outcome may obscure two deeper paradoxes. First, an unaddressed expert-center ceiling effect may limit generalizability. All 28 centers that participated in the trial were high-volume centers (>600 percutaneous coronary interventions [PCIs] per year) with routine use of intravascular sonography (IVUS) (in 50 to 100% of cases). In the angiography group, the percentages of patients who underwent dilation after stent implantation (96.0%) and use of balloon inflation in the proximal . . .
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A 2026 study conducted a letter in Left main coronary disease. Intravascular ultrasound (IVUS)-guided PCI vs. Angiography-guided PCI was evaluated. IVUS-guided PCI in the OPTIMAL trial may have shown a neutral outcome due to an expert-center ceiling effect across 28 high-volume centers (>600 PCIs/year) with 96.0% post-dilation in the control arm.
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