Outcomes After Left Main Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting According to Lesion Site: Results From the EXCEL Trial
The authors sought to determine the extent to which the site of the left main coronary artery (LM) lesion (distal bifurcation versus ostial/shaft) influences the outcomes of revascularization with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG).
Background
Among 1,905 patients with LM disease and site-assessed SYNTAX scores of <32 randomized in the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, revascularization with PCI and CABG resulted in similar rates of the composite primary endpoint of death, myocardial infarction (MI), or stroke at 3 years.
Methods
Outcomes from the randomized EXCEL trial were analyzed according to the presence of angiographic core laboratory–determined diameter stenosis ≥50% involving the distal LM bifurcation (n = 1,559; 84.2%) versus disease isolated to the LM ostium or shaft (n = 293; 15.8%).
Results
At 3 years, there were no significant differences between PCI and CABG for the primary composite endpoint of death, MI, or stroke for treatment of both distal LM bifurcation disease (15.6% vs. 14.9%, odds ratio [OR]: 1.08, 95% confidence interval [CI]: 0.81 to 1.42; p = 0.61) and isolated LM ostial/shaft disease (12.4% vs. 13.5%, OR: 0.90, 95% CI: 0.45 to 1.81; p = 0.77) (pinteraction = 0.65). However, at 3 years, ischemia-driven revascularization occurred more frequently after PCI than CABG in patients with LM distal bifurcation disease (13.0% vs. 7.2%, OR: 2.00, 95% CI: 1.41 to 2.85; p = 0.0001), but were not significantly different in patients with disease only at the LM ostium or shaft (9.7% vs. 8.4%, OR: 1.18, 95% CI: 0.52 to 2.69; p = 0.68) (pinteraction = 0.25).
Conclusions
In the EXCEL trial, PCI and CABG resulted in comparable rates of death, MI, or stroke at 3 years for treatment of LM disease, including those with distal LM bifurcation disease. Repeat revascularization rates during follow-up after PCI compared with CABG were greater for lesions in the distal LM bifurcation but were similar for disease isolated to the LM ostium or shaft.
Dr. Gershlick has received lecture fees and travel support from Abbott Vascular. Dr. Kandzari has received consulting fees from Medtronic, Boston Scientific, and Micell; and grant support from Medtronic, Abbott Vascular, Boston Scientific, Biotronik, and Medinol. Dr. Lembo has received fees for lectures and for serving on advisory boards from Abbott Vascular, Boston Scientific, and Medtronic. Prof. A.P. Banning is partially funded by The NIHR Oxford Biomedical Research Centre; and has received lecture fees from Abbott Vascular, and Boston Scientific; and institutional research funding from Boston Scientific. Dr. Merkely has received lecture fees and institutional grant support from Abbott. Dr. Sabik has received fees for serving on advisory boards from Medtronic; and is a consultant for Medtronic, Edwards Lifesciences, and Sorin. Dr. Serruys has receiving consulting fees from Abbott, Biosensors, Medtronic, Micell Technologies, QualiMed, SINOMED, St. Jude Medical, Stentys, Svelte Medical Systems, Philips/Volcano, and Xeltis. Dr. Kappetein is an employee of Medtronic. Dr. Stone’s employer, Columbia University, receives royalties for sale of the MitraClip. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
