Abstract
Background Current recommendations for the best views for the left main coronary artery (LMCA) ostium intervention are empirical. Objectives To determine the optimal projection to visualize the LMCA ostium using only fluoroscopy. Methods The optimal projection to visualize the LMCA ostium was determined using fluoroscopic images of superimposing the lowest points of the distal ends of two J tipped wires in the noncoronary cusp (NCC) and right coronary cusp (RCC). This was validated independently using 3-dimensional computed tomography (3D-CT) reconstruction. Results Satisfactory images of the overlapping wires in NCC and RCC could be obtained in 90% (45/50). Between the fluoroscopic and the 3D-CT reconstruction approaches, the mean difference for NCC and RCC overlapping at horizontal axes is -1.8 with a 95% limit of agreement between −3.94 and 0.34 (p=0.10) and at vertical axes −1.6 with a 95% limit of agreement between −3.46 and 0.26 (p=0.09); and the mean difference for the optimal projection to visualize the LMCA ostium at horizontal axes is −3.22 with a 95% limit of agreement between -7.26 and 0.81 (p=0.11) and at vertical axes −2.31 with a 95% limit of agreement between −5.83 and 1.21 (p=0.09). The 3D angulation deviation for the optimal projection to visualize the LMCA ostium was 8.5° ± 4.7° when the LMCA ostium faced the NCC-RCC commissure (n = 32) and 22.3° ± 16.0° (p=0.009) when it did not (n = 13). Conclusions The optimal projection for LMCA ostial intervention can be determined using fluoroscopic images of superimposing wires in the NCC and RCC when the LMCA ostium faces the NCC-RCC commissure, as was the case in 71% of the patients studied.
Highlights
A good fluoroscopic working view provides essential anatomical landmarks that are crucial during left main coronary artery (LMCA) ostial stent implantation, and the stent must cover the LMCA ostium without too much protrusion to the aorto that would make future intervention more difficult [1, 2]
The wire in the noncoronary cusp (NCC) would be at the left side and the wire in the right coronary cusp (RCC) would be at the right side. en, the C-arm was rotated in the left anterior oblique (LAO) and cranial directions until the lowest points in the curve at the distal part of these two wires were superimposed (Figure 1(b)), in which NCC and RCC would be considered as overlapping. is view angulation of the overlapping NCC and RCC was considered as the optimal projection to visualize the LMCA ostium. e LMCA ostial image was recorded using angiography of the left coronary artery (Figure 1(c))
E angle between the LM ostium and the NCC-RCC commissure was measured. e center of the cusp plane was defined as the angular vertex. e line crossing the commissure and the center of the cusp plane was defined as one side of the angle. e line crossing the center of LMCA ostium and the center of the cusp plane was defined as another side of the angle. e ostium was considered to be facing the NCC-RCC commissure when the LMCA ostium was on the line crossing the commissure and the center of the cusp plane (Figure 4)
Summary
A good fluoroscopic working view provides essential anatomical landmarks that are crucial during left main coronary artery (LMCA) ostial stent implantation, and the stent must cover the LMCA ostium without too much protrusion to the aorto that would make future intervention more difficult [1, 2]. The optimal fluoroscopic working view can be determined using 3-dimensional computed tomography (3D-CT) reconstruction software if the patient has undergone coronary CT or electrocardiographically gated ascending aortic CT before the angiography-guided procedure [4, 5]. It has not been reported if the optimal fluoroscopic working view for LMCA ostial stent implantation can be determined using only fluoroscopic images. We propose an approach based on fluoroscopic images of overlapping wires in the aortic cusps and validate this approach with 3D-CT reconstruction software
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