OCT for Optimizing Long-Term Clinical Results in Left Main PCI—Dream or Reality? Results from a Single-Center High-Volume Registry

<b>Background:</b> With growing evidence regarding long-term clinical results of left main angioplasty, it has become clear that the gap between percutaneous coronary interventions (PCIs) and bypass surgery can be narrowed only by improving the PCI technique. While intravascular ultrasound (IVUS) has become routinely used for this subset of lesions, there is still insufficient data regarding the role of optical coherence tomography (OCT) in left main PCI. <b>Aims:</b> The aim of this study was to investigate the long-term results of OCT-guided PCI in comparison to angiographical guidance alone. <b>Material and methods:</b> We conducted a retrospective single-center high-volume analysis of patients with left main disease treated by PCI. The primary endpoint was all-cause death. <b>Results and discussion:</b> Between January 2013 and January 2024, we enrolled 221 eligible patients with unprotected left main coronary artery disease treated by PCI; among these, 13.1% were treated by OCT-guided PCI and 86.9% by angiographic-guided PCI. At a median follow up of 30.16 months (interquartile range: 14.3-60 months), Kaplan-Meier survival analysis revealed a significantly higher survival probability in the OCT group compared to the non-OCT group (log-rank <i>p</i> = 0.034), with no significant differences between the groups regarding procedural success rate. In the multivariable Cox proportional hazards model, adjusting for other relevant covariates, OCT was borderline non-significantly independently associated with a 63% reduction in mortality (HR = 0.37, <i>p</i> = 0.063). <b>Conclusions:</b> In our study, OCT-guided PCI was associated with early procedural distinctions and a trend toward improved unadjusted survival in LM PCI. The findings highlight the potential procedural advantages of OCT, as well as the need for larger prospective studies to establish its long-term clinical benefits in left main interventions.