- The Left Main Lithotripsy Case
- Board Fact 1: Device Comparison
- Board Fact 2: Randomised Trials
- Board Fact 3: C2+ Numbers for Left Main Lithotripsy
- Board Fact 4: Fujino OCT Calcium Score
- Board Fact 5: Left Main Lithotripsy Registry Evidence
- Board Fact 6: Tolerating Left Main Lithotripsy
- Board Fact 7: Guide and Stent Optimisation
- Five Left Main Lithotripsy MCQs
- References
Left main lithotripsy is now a favourite examiner topic because it tests five decisions at once: device, occlusion tolerance, test balloon, guide and aorto-ostial finish. This revision sheet turns one planning-stage case into seven high-yield board facts, five reference tables and five single-best-answer questions.
The Left Main Lithotripsy Case
- Woman, 75 years; LVEF 60%.
- Mid-RCA already treated with PCI: her “lifeline” while the LM is occluded.
- LM: 360° calcium, ostium to distal body; reference ~4.5 mm.
- Mid-LAD 80%; proximal LCx 90%.
- Status: planning only. No procedural outcome is reported.
Heart team first: PCI and CABG fared comparably in EXCEL and NOBLE for isolated ostial or shaft LM with low SYNTAX. This sheet assumes PCI was chosen.
Board Fact 1: Device Comparison
IVUS leads; OCT cannot reliably clear blood from a true aorto-ostium. Then ask: crossable or not, concentric or nodular?
| Device | Mechanism | Best lesion | Aorto-ostial LM limitation |
|---|---|---|---|
| RA | Diamond burr ablates superficial calcium | Uncrossable; calcified nodule | Slow-flow risk in diffuse LM calcium; burr entrapment |
| OA | Eccentric crown orbits and sands | Non-ostial superficial calcium | Crown cannot orbit safely; guide instability; eccentric sanding |
| IVL | Acoustic waves fracture superficial and deep calcium | Crossable, concentric, thick, long | Max 4.0 mm balloon; occlusive cycles; weaker on nodules |
| ELCA | Excimer photoablation | Bail-out: uncrossable, stent underexpansion | Failed non-inferiority to RA |
| Cutting/scoring balloon | Blades or wires incise plaque | Thinner, <360° fibrocalcific | Often insufficient; dissection towards aortic root |
- Crossable 360° ring, >0.5 mm thick, >5 mm long: left main lithotripsy first. Least perforation and slow flow; no burr to trap.
- 1.5 mm balloon will not cross, or no IVL wall contact: 1.25–1.5 mm burr, then IVL (“RotaTripsy”).
- Eccentric nodule: RA, then NC/OPN balloon.
Board Fact 2: Randomised Trials
| Trial | n | Comparison | Primary result |
|---|---|---|---|
| PREPARE-CALC (2018) | 200 | Modified balloon vs RA | Strategy success 81% vs 98%; 9-month LLL 0.16 vs 0.22 mm (non-inferior) |
| ROLLER COASTR-EPIC22 (2025) | 171 | RA vs IVL vs ELCA | OCT expansion 86.4% vs 85.6%: IVL non-inferior; ELCA 80.3% failed |
| ICARE OFDI (2026) | 169 | RA vs IVL | MSA 5.9 vs 6.0 mm²: IVL non-inferior |
| ECLIPSE (2025) | 2,005 | OA vs balloon | MSA 7.67 vs 7.42 mm² (p=0.08); 1-year TVF 11.5% vs 10.0%: OA not superior |
ICARE OFDI extras: major malapposition 80.2% RA vs 57.8% IVL (p=0.002); RA still indispensable for uncrossable lesions.
Board trap: no randomised IVL-versus-RA trial has enrolled the left main. ROLLER COASTR studied 2.5–4.0 mm vessels; ICARE OFDI excluded the LM. Left main lithotripsy rests on registries and case reports.
Board Fact 3: C2+ Numbers for Left Main Lithotripsy
| Parameter | IFU value | This 4.5 mm LM |
|---|---|---|
| Sizes | 2.5 / 3.0 / 3.5 / 4.0 × 12 mm | 4.0 × 12 (~0.9:1) |
| Sizing rule | 1:1; else largest | Largest available |
| Treatment pressure | 4 atm | Higher = off-label |
| RBP | 10 atm | Do not exceed |
| Pulses per cycle | 10 | 5 if borderline |
| Pause | ≥10 s | Wait for full recovery |
| Same segment | ≤80 pulses | Ostial and distal body |
| Per catheter | ≤120 pulses | Budget across both sites |
- Ostial position: 1–2 mm of balloon in the aorta.
- IVUS shows where the balloon meets calcium: the narrowed segments.
- Never park a 4.0 balloon in a proximal LAD under 3.5–4.0 mm.
Board Fact 4: Fujino OCT Calcium Score
| OCT feature | Threshold | Points |
|---|---|---|
| Maximum calcium angle | >180° | 2 |
| Maximum thickness | >0.5 mm | 1 |
| Length | >5 mm | 1 |
| Score 0–3 | Stent expansion 96% | |
| Score 4 | Stent expansion 78% (p<0.01) | |
Application: this 360°, ostial-to-distal ring scores at least 3 on angle and length. IVUS shadowing hides thickness, so treat it as score 4 (an extrapolation from an OCT score): left main lithotripsy before any stent.
Board Fact 5: Left Main Lithotripsy Registry Evidence
| Source | Population | High-yield LM finding |
|---|---|---|
| BENELUX-IVL LM (Oliveri 2025) | 59 LM vs 450 non-LM | Older, EF 41% vs 51%; MCS 6.8% vs 2.1%; success 93.2% vs 89.8%; 1-year outcomes comparable |
| Skorupski 2025 | 53 LM vs 148 non-LM | 4.0 mm balloon 15.1% vs 2.0%; success 100%; no perforation or no-reflow |
| Sandesara 2023 | 107 distal LM: IVL 50, RA-only 57 | Success 98% vs 86% (p=0.04); bail-out MCS: 1 RA, 0 IVL |
| Oliveri 2024 aorto-ostial | 48 aorto-ostial of 321 | Residual <30% 81.3% vs 90.5% (recoil); in-hospital MACE 4.2% vs 0.7% |
| Kosowski 2022 (case) | 85-year-old woman, ostial LM | C2 3.5 × 12, 80 pulses at 4 atm; stable; no MCS |
A 2023 JSCAI review of left main lithotripsy pooled 148 patients, mostly distal LM: success 86.4–100%, no RCTs.
Board Fact 6: Tolerating Left Main Lithotripsy
Occlusion physiology
- One cycle (4 atm, 10 pulses at 1 Hz, 6 atm, deflate) occludes the LM ~15–20 s, like any NC inflation during LM stenting.
- Favourable: EF 60%, patent RCA. Confirm the RCA result first.
- Poor-tolerance flags: hypotension, LVEDP >~20 mmHg, significant AS/MR, recent MI, damping.
Set-up for every cycle
- MAP >80–85 mmHg; pressor drawn up; atropine; defibrillator pads.
- Guide disengaged in the aorta during pulses.
- Pause until ST, pressure and symptoms recover (often 30–90 s), not just 10 s.
- Borderline: 5 pulses per inflation (Salazar/Escaned).
- LCx buddy wire; ACT >250–300 s; 6F femoral bail-out sheath.
Prophylactic MCS is not routine here. Impella-protected cases had other drivers: LAD CTO (Sinning) or EF 25% (Chaddad).
Test inflation: NC, not cutting
- NC 3.0 × 8–12 mm (~0.65:1), ≤12 atm, 15–20 s, guide disengaged.
- Recovery <30–60 s: no support needed. Waist at 12 atm: IVL confirmed.
- Marked drop, VT or slow recovery: shorter cycles on pressors, RA first, or Impella CP.
- Cutting balloon: slow inflation, blurred read-out, aortic-root dissection.
Board Fact 7: Guide and Stent Optimisation
Guide: EBU 3.5, 7F, no side holes
- EBU: backup for LAD and LCx delivery; JL is weak for the LCx.
- 3.5, not 4.0: smaller aortic root in older women; a 4.0 engages deeply.
- Avoid AL1: deep intubation, dissection.
- 7F: two-NC kissing, two wires plus IVUS, or a 1.75 mm burr. IVL itself is 6F compatible.
- No side holes: they hide damping and dilute contrast.
- Engage to image; disengage to treat.
Stent optimisation at the aorto-ostium
- After left main lithotripsy, confirm fracture with a 4.5 NC at high pressure under IVUS.
- DES, 4.0–4.5 mm platform; 1–2 mm aortic protrusion; POT with 5.0 NC; flare the ostium.
- MSA floor (common IVUS thresholds, used by Sandesara): LM >8.2, ostial LAD >6.3, ostial LCx >5.0 mm².
- Operator target: ≥80–90% of ~16 mm² reference (12–13 mm²).
- Recoil is the aorto-ostial enemy (Oliveri 2024).
- Medina 1,1,1: DK-crush or culotte, LM prepared first.
Five Left Main Lithotripsy MCQs
MCQ 1
Before left main lithotripsy in this 4.5 mm LM, the best test-inflation balloon is:
A. 3.0 mm cutting balloon
B. 3.0 × 8–12 mm NC, ≤12 atm, 15–20 s
C. 4.5 mm semi-compliant balloon
D. 3.5 mm scoring balloon
E. 5.0 mm NC at 20 atm
Answer: B. An undersized NC mimics one IVL cycle predictably and gives a clean dilatability read-out. Cutting balloons inflate slowly and risk aortic-root dissection.
MCQ 2
The best guide for ostial-to-distal LM calcium with LAD and LCx disease in a 75-year-old woman is:
A. JL 4.0, 6F
B. AL1, 7F
C. EBU 3.5, 7F, no side holes
D. EBU 4.0, 6F, side holes
E. JL 3.5, 7F, side holes
Answer: C. EBU gives LCx backup; 3.5 suits a smaller root; 7F allows kissing and IVUS. Side holes mask damping.
MCQ 3
A 1.5 mm balloon fails to cross the calcified LM. Next step:
A. 4.0 mm IVL catheter
B. RA, 1.25–1.5 mm burr, then IVL
C. Orbital atherectomy
D. Cutting balloon
E. Routine first-line laser
Answer: B. IVL needs a crossable lesion with wall contact. A small burr creates the channel (“RotaTripsy”); laser is bail-out only.
MCQ 4
Orbital atherectomy is avoided at an aorto-ostial LM chiefly because:
A. It needs an 8F guide
B. It is contraindicated in women
C. The crown must orbit in-vessel; guide instability causes eccentric sanding
D. It cannot treat arcs >180°
E. It mandates MCS
Answer: C. The ostium offers no stable lumen for the orbit. ECLIPSE also showed no advantage over balloon preparation.
MCQ 5
Which Shockwave C2+ statement is correct?
A. Largest size 4.5 × 12 mm
B. Largest 4.0 × 12 mm; ≤80 pulses per segment; 120 per catheter
C. Treatment pressure 10 atm
D. 20 pulses per cycle
E. No pause between cycles
Answer: B. Treatment is at 4 atm (RBP 10), 10 pulses per cycle, pause ≥10 s. For left main lithotripsy in a 4.5 mm LM, 4.0 mm is the ceiling.
References
- Abdel-Wahab et al. PREPARE-CALC. Circ Cardiovasc Interv. 2018.
- Jurado-Román et al. ROLLER COASTR-EPIC22. JACC Cardiovasc Interv. 2025.
- Honton et al. ICARE OFDI. EuroIntervention. 2026.
- ECLIPSE Investigators. Orbital atherectomy vs balloon angioplasty. Lancet. 2025.
- Fujino et al. OCT calcium scoring system. EuroIntervention. 2018.
- Oliveri et al. BENELUX-IVL left main analysis. Int J Cardiol. 2025.
- Skorupski et al. IVL in LM vs non-LM. Postepy Kardiol Interwencyjnej. 2025.
- Sandesara et al. IVL vs RA in distal LM. Catheter Cardiovasc Interv. 2023.
- Oliveri et al. IVL in aorto-ostial lesions. Catheter Cardiovasc Interv. 2024.
- Kosowski et al. IVL of ostial LM. Kardiol Pol. 2022.
- Salazar et al. IVL in distal LM. JACC Case Rep. 2019.
- IVL for calcified LM: systematic review. JSCAI. 2023.
- Shockwave Medical. C2+ coronary IVL catheter IFU. 2024.
- Sinning et al. Protected LM PCI case. Eur Heart J Suppl. 2026.
- Chaddad et al. Impella-supported LM case. Int J Surg Case Rep. 2025.
