The Value of Independent Specialty Designation for Interventional Cardiology. DOI: 10.1002/ccd.26656

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<h4>Background</h4>Optimal stent expansion is a key determinant of long-term outcomes after PCI. Intravascular imaging provides the most accurate assessment of stent deployment but remains underused, especially in older patients with MI and multivessel disease. ESV is an angiographic enhancement technology that may help detect gross stent underexpansion when advanced imaging is not feasible.<h4>Aims</h4>To evaluate the procedural and clinical impact of enhanced stent visualization (ESV)-guided percutaneous coronary intervention (PCI) in older patients with myocardial infarction (MI) and multivessel disease.<h4>Methods</h4>In this prespecified sub-study of the FIRE trial, we evaluated the impact of ESV use during PCI in older MI patients. Among 1445 enrolled patients, 331 underwent ESV-guided PCI and 1114 standard angiography-guided PCI. Procedural optimization triggered by ESV was defined as additional postdilation, extra stent implantation, or use of intravascular imaging. Minimal lumen diameter (MLD) was assessed before and after ESV-guided optimization. Clinical outcomes were compared using multivariable and competing-risk adjusted Cox models.<h4>Results</h4>Operator-driven optimization occurred in 85% of ESV cases, primarily through postdilation (96%). ESV guidance resulted in a significant MLD increase from 2.51 [2.22-2.87] to 2.93 [2.41-3.32] mm (p < 0.001), yielding an acute luminal gain of 0.42 mm (95% CI 0.37-0.47). At 3 years, the composite primary endpoint (death, MI, stroke, or ischemia-driven revascularization) was lower in the ESV group (adjusted HR 0.70, 95% CI 0.54-0.91; p = 0.008).<h4>Conclusions</h4>In older MI patients with complex multivessel disease, ESV-guided PCI was associated with greater procedural optimization, improved acute stent expansion, and lower long-term adverse events. While not a substitute for intracoronary imaging, ESV represents a pragmatic and valuable adjunct to enhance PCI quality in settings where intravascular imaging is seldom performed.<h4>Trial registration</h4>ClinicalTrials.gov identifier NCT03772743.

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