CBS 2019
CBSMD教育中心
中 文

Stenting Left Main

Abstract

Recommended Article

What Is the Optimal Revascularization Strategy for Left Main Coronary Stenosis? Why NOBLE and EXCEL Are Consistent With Each Other and With Previous Trials Current treatment of significant left main coronary artery disease: A review Comparison of Outcomes of Percutaneous Coronary Intervention on Native Coronary Arteries Versus on Saphenous Venous Aorta Coronary Conduits in Patients With Low Left Ventricular Ejection Fraction and Impella Device Implantation Achieved or Attempted (from the PROTECT II Randomized Trial and the cVAD Registry) Percutaneous coronary intervention in left main coronary artery disease: the 13th consensus document from the European Bifurcation Club Percutaneous coronary intervention for the left main stem and other bifurcation lesions: 12th consensus document from the European Bifurcation Club Surgical ineligibility and mortality among patients with unprotected left main or multivessel coronary artery disease undergoing percutaneous coronary intervention Patient selection and percutaneous technique of unprotected left main revascularization

Clinical Trial2019 Mar 28. [Epub ahead of print]

JOURNAL:Eur Heart J. Article Link

Impact of large periprocedural myocardial infarction on mortality after percutaneous coronary intervention and coronary artery bypass grafting for left main disease: an analysis from the EXCEL trial

Ben-Yehuda O, Chen S, Stone GW et al. Keywords: Coronary artery bypass grafting; Left main coronary artery; Percutaneous coronary intervention; Periprocedural myocardial infarction; Revascularization

ABSTRACT


AIMS - The prognostic implications of periprocedural myocardial infarction (PMI) after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) remain controversial. We examined the 3-year rates of mortality among patients with and without PMI undergoing left main coronary artery intervention randomized to PCI with everolimus-eluting stents vs. CABG in the large-scale, multicentre, prospective, randomized EXCEL trial.

 

METHODS AND RESULTS - By protocol, PMI was defined using an identical threshold for PCI and CABG [creatinine kinase-MB (CK-MB) elevation >10× the upper reference limit (URL) within 72 h post-procedure, or >5× URL with new Q-waves, angiographic vessel occlusion, or loss of myocardium on imaging]. Cox proportional hazards modelling was performed controlling for age, sex, hypertension, diabetes mellitus, left ventricular ejection fraction, SYNTAX score, and chronic obstructive pulmonary disease (COPD). A total of 1858 patients were treated as assigned by randomization. Periprocedural MI occurred in 34/935 (3.6%) of patients in the PCI group and 56/923 (6.1%) of patients in the CABG group [odds ratio 0.61, 95% confidence interval (CI) 0.40-0.93; P = 0.02]. Periprocedural MI was associated with SYNTAX score, COPD, cross-clamp duration and total procedure duration, and not using antegrade cardioplegia. By multivariable analysis, PMI was associated with cardiovascular death and all-cause death at 3 years [adjusted hazard ratio (HR) 2.63, 95% CI 1.19-5.81; P = 0.02 and adjusted HR 2.28, 95% CI 1.22-4.29; P = 0.01, respectively]. The effect of PMI was consistent for PCI and CABG for cardiovascular death (Pinteraction = 0.56) and all-cause death (Pinteraction = 0.59). Peak post-procedure CK-MB 10× URL strongly predicted mortality, whereas lesser degrees of myonecrosis were not associated with prognosis.

 

CONCLUSION - In the EXCEL trial, PMI was more common after CABG than PCI, and was strongly associated with increased 3-year mortality after controlling for potential confounders. Only extensive myonecrosis (CK-MB 10× URL) was prognostically important.

 

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email-  journals.permissions@oup.com.