Bifurcation left main stenting with or without intracoronary imaging: Outcomes from the EBC MAIN trial

Background: The impact of intracoronary imaging on outcomes, after provisional versus dual-stenting for bifurcation left main (LM) lesions, is unknown. Objectives: We investigated the effect of intracoronary imaging in the EBC MAIN trial (European Bifurcation Club Left Main Coronary Stent study). Methods: 467 patients were randomised to dual-stenting or a stepwise provisional strategy. 455 patients were included. Intravascular ultrasound (IVUS) or optical coherence tomography (OCT) was undertaken at the operator's discretion. The primary endpoint was death, myocardial infarction or target vessel revascularisation at 1-year. Results: Intracoronary imaging was undertaken in 179 patients (39%; IVUS n=151, OCT n=28). As a result of IVUS findings, operators re-intervened in 42 procedures. The primary outcome did not differ with intracoronary imaging versus angiographic-guidance alone (17% vs. 16%; odds ratio (OR): 1.09 [95% confidence interval (CI): 0.66-1.82] p=0.738), nor for re-intervention based on IVUS versus none (14% vs.16%; OR: 0.86 [95% CI: 0.35-2.12] p=0.745). With angiographic-guidance only, primary outcome events were more frequent with dual versus provisional stenting (21% vs. 10%; OR: 2.24 [95% CI: 1.13-4.45] p=0.022). With intracoronary imaging, there were numerically fewer primary outcome events with dual versus provisional stenting (13% vs. 21%; OR: 0.54 [95% CI: 0.24-1.22] p=0.137). Conclusions: In EBC MAIN, the primary outcome did not differ between patients who did or did not have intracoronary imaging. However, in patients without intracoronary imaging, outcomes were worse with a dual-stent than provisional strategy, and when intracoronary imaging was used, there was a trend toward better outcomes with the dual-stent than provisional strategy.