SOLEMN Study - Synergy Optical Coherence Tomography in Left Main PCI (SOLEMN)

BACKGROUD: Percutaneous coronary intervention (PCI) is increasingly used to treat unprotected left main coronary artery stenosis. Protected LM PCI is considered standard of care in most centers. OCT allows for precise determination of stent placement, stent expansion and apposition. The pattern of vessel healing can be very precisely studied if immediate post-stent implantation OCT/IVUS data is compared to the 6-month post-PCI interval. While OCT cannot be optimally used for ostial lesion imaging, IVUS can be used to image ostial lesions/stent placement. Optimal and consistent vessel healing is particularly important in LM PCI where stent thrombosis is a potential complication with serious adverse outcome. HYPOTHESIS: Due to the absorption of the polymer of the Boston Scientific Synergy Stent over time, early strut coverage patterns and timeline may be different than previously observed in DES and BMS stents in LM PCI. Late acquired stent malapposition (LASM) is expected to differ from previous observations with traditional DES/BMS. Stent coverage in LM PCI will be studied with OCT or IVUS at six and 12 months and compared to OCT or IVUS at the time of stent implantation. OCT/IVUS data will be analyzed in a core lab (CRF) and correlated with clinical outcomes at 6 and 12 months.

The proposed study is a multicenter, observational, prospective, single-arm study of stent strut coverage of patients undergoing LM PCI. Baseline quantitative coronary analysis (QCA) will be performed at the time of stent implantation. Stent coverage in LM PCI will be studied with OCT at 3 and 12 months and compared to baseline OCT at the time of stent implantation.(31, 32) OCT/data will be analyzed in a core lab (CTC CRF) and correlated with clinical outcomes at 3 and 12 months. Primary Endpoint • 3-month stent strut coverage in LM PCI Secondary Endpoints 12-month stent strut coverage in LM PCI 3-month late acquired stent malapposition (LASM) 12-month late acquired stent malapposition (LASM) One-month LM Synergy stent safety 1-, 3- and 12-month MACE 1-, 3- and 12-month Stent Thrombosis (ST) (ARC definition) 75 patients undergoing LM PCI (protected or unprotected) with Boston Scientific Synergy™ stent. The goal is to enroll 75 patients from up to 10 VA sites and an enrollment period of 3 years, each site is expected to include 7-10 patients during the study period. After a total of 75 patients are enrolled the study will be closed for further enrollment. Eligible patients will be screened at each participating center and those who had undergone LM PCI with Boston Scientific Synergy™ stent and where OCT was performed during the index procedure will be eligible. The index procedure may be performed by any interventional cardiologist - this is specifically needed in order to maintain equipoise on the part of stent choice and use of OCT. At the end of the study enrollment period, the proportion of patients at each site treated with Synergy stents vs. non-Synergy stents and the proportion of patients that underwent OCT imaging during LM PCI will be collected. Eligible patients will be approached and consented for inclusion in the SOLEMN trial after the initial procedure. Study Duration Patients will be followed for 12 months after the index procedure. At one month, clinical follow-up will be performed (clinic or telephone). At 3 months, the angiography and OCT will be performed. At 12 months, the final angiography and OCT will be performed. No further follow-up is planned after completion of the 3- and 12-month angiography and OCT.

Percutaneous Coronary Intervention, Optical Coherence Tomography, In-stent Coronary Artery Restenosis

Patients who have undergone clinically-indicated PCI of LM where OCT was performed as part of the routine index procedure will be approached for the study and enrolled if eligible.

OCT will be performed with the St. Jude OCT system. Detection of metallic stent struts will be performed automatically with manual adjustments made as necessary. Stent area tracings will be automatically performed by interpolated contours connecting the center point of the luminal surface of each detected metallic strut. Stent expansion will be determined as the minimum stent area divided by the average reference lumen area and presented as a percentage. Neo-intimal hyperplasia (NIH) area will be determined in follow-up examinations as the area between the stent and lumen contours. Incomplete stent apposition (ISA) area will be determined as the area between the stent contour and the lumen contour at the site of malapposed struts, in a region not overlying a side branch ostium.

The stent strut coverage is specifically defined as Percentage of Uncovered Stent Struts. The Percentage of Uncovered Stent Struts is the number of struts without distinct overlying tissue, in which the luminal reflection of the strut surface is directly interfacing with the lumen, divided by total number of analyzable struts.

The stent strut coverage is specifically defined as Percentage of Uncovered Stent Struts. The Percentage of Uncovered Stent Struts is the number of struts without distinct overlying tissue, in which the luminal reflection of the strut surface is directly interfacing with the lumen, divided by total number of analyzable struts.

Malapposition will be defined as a measured distance greater than the total thickness of the stent metal plus polymer of the stent.

MACE include: Death Myocardial infarction Stroke (cerebrovascular accident or CVA) Urgent revascularization Repeat revascularization Bleeding Stent thrombosis Rehospitalization

Inclusion criteria: Age 18 years or greater; Left Main CAD, defined as ≥ 50% diameter stenosis and amenable to re-vascularization by PCI; Willing and able to give informed consent. The patients must be able to comply with study procedures and follow-up. Ability to comply with minimum of 6 months of DAPT after the index procedure. Unprotected Left Main PCI Protected Left Main PCI Exclusion criteria: Coexisting conditions that limit life expectancy to less than 12 months or that could affect patient's compliance with the protocol; Serum creatinine greater than 2.0 mg/dL; Cardiogenic shock; STEMI; Non-STEMI, if the cardiac troponin is not stable or starting to decline; Pregnancy; Inability to take dual antiplatelet therapy for 6 months; Any target lesion with previously placed stent. Patients disqualified for CABG surgery. Contraindications for OCT use: Bacteremia or sepsis Major coagulation system abnormalities Severe hemodynamic instability or shock Patients diagnosed with coronary artery spasm Acute renal failure