Intracoronary Imaging Implementation Gap in Contemporary PCI

BACKGROUND: Intracoronary imaging improves outcomes in complex percutaneous coronary intervention (PCI), yet its implementation in routine practice remains inconsistent. OBJECTIVES: This study sought to quantify the implementation gap for intracoronary imaging in contemporary PCI, identify operator-reported barriers to its use when predefined guideline-based anatomic criteria were present, and characterize modality selection beyond those criteria. METHODS: OCT2ACT was a prospective, multicenter study enrolling 1,189 consecutive patients across 23 Italian imaging-capable centers between September 15 and December 15, 2025. Patients were classified as follows: cohort 1, predefined class IA anatomic criteria with no imaging; cohort 2, predefined class IA anatomic criteria with imaging; and cohort 3, imaging use outside these criteria. RESULTS: Among 908 patients meeting predefined class IA criteria, 481 (53.0%) did not undergo intracoronary imaging. The most frequent barriers were operator-reported attitudinal factors, with angiography considered sufficient or imaging judged unlikely to change PCI strategy in 278 patients (57.8%). Imaging uptake varied substantially across centers (16.7% to 100.0%). In cohort 2, IVUS was the predominant modality (72%), whereas in cohort 3 optical coherence tomography was more common (54%), mainly for diagnostic clarification in ambiguous acute coronary syndromes or stent failure. CONCLUSIONS: Even in imaging-capable centers, intracoronary imaging remains underused in anatomically complex PCI. This implementation gap appears driven predominantly by operator attitudes and intersite practice variation rather than by cost or technical barriers alone. (Barriers Limiting OCT Penetration in Clinical Practice [OCT2ACT]; NCT07193693).