Intravascular imaging improves outcomes in left main PCI: insights from acute and chronic presentations

Percutaneous coronary intervention (PCI) has emerged as an established revascularization strategy for selected patients with left main coronary artery (LMCA) disease. However, data regarding outcomes in unselected real-world populations and the impact of intravascular imaging remain limited. We aimed to evaluate clinical outcomes following LMCA PCI according to clinical presentation and to assess the prognostic impact of intravascular imaging guidance. We conducted a retrospective single-centre study including consecutive patients undergoing LMCA PCI between 2019 and 2022. Patients were classified as having chronic (CCS) or acute coronary syndrome (ACS). Major adverse cardiac and cerebrovascular events (MACCE) were assessed during follow-up. Kaplan–Meier and Cox regression and stabilised inverse probability of treatment weighting (SIPTW) analyses were performed. A total of 107 patients were included (19 CCS and 88 ACS; mean age 68.6 ± 11.3 years; 80.4% male). During a mean follow-up of 1121 ± 574 days, ACS patients experienced higher rates of MACCE (40.9% vs. 15.8%; p = 0.039) and all-cause mortality (29.5% vs. 5.3%; p = 0.027) compared with CCS patients. Intravascular imaging-guided PCI was associated with a significantly lower risk of MACCE in multivariable analysis (HR 0.32, 95% CI 0.14–0.75; p = 0.009). In a SIPTW-adjusted analysis, the association remained directionally favourable, although statistical significance was not maintained (HR 0.57, 95% CI 0.26–1.29; p = 0.178). Clinical presentation significantly influences outcomes after LMCA PCI, with worse long-term prognosis among ACS patients. Intravascular imaging-guided PCI was associated with lower rates of MACCE and remained directionally favourable after weighting analyses, supporting its role in optimising LMCA interventions.