Impact of Incomplete Revascularization After PCI in Left Main Disease: The EXCEL Trial.

IF 6.1 1区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS Circulation: Cardiovascular Interventions Pub Date : 2024-03-01 Epub Date: 2024-03-19 DOI:10.1161/CIRCINTERVENTIONS.123.013192

Ziad A Ali, Javier Jas Garcia, Keyvan Karimi Galougahi, Jennifer Horst, Anthony Gallo, Doosup Shin, Ori Ben-Yehuda, Shmuel Chen, Björn Redfors, Arie Pieter Kappetein, Joseph F Sabik, Patrick W Serruys, Gregg W Stone

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Abstract

Background: The importance of complete revascularization after percutaneous coronary intervention (PCI) in patients with left main coronary artery disease is uncertain. We investigated the clinical impact of complete revascularization in patients with left main coronary artery disease undergoing PCI in the EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization).

Methods: Composite rates of death or myocardial infarction (MI) following PCI during 5-year follow-up were examined in 903 patients based on core laboratory definitions of anatomic and functional complete revascularization, residual SYNTAX score (The Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery), and residual Jeopardy Score (rJS).

Results: The risk of death or MI did not vary based on anatomic, functional, or residual SYNTAX score complete revascularization but did differ according to the rJS (5-year rates 17.6%, 19.5%, and 38.9% with rJS 0, 2, and ≥4, respectively; P=0.006). The higher rate of death or MI with rJS≥4 versus rJS≤2 was driven conjointly by increased mortality (adjusted hazard ratio, 2.29 [95% CI, 1.11-4.71]; P=0.02) and spontaneous MI (adjusted hazard ratio, 2.89 [95% CI, 1.17-7.17]; P=0.02). The most common location for untreated severe stenoses in the rJS≥4 group was the left circumflex artery (LCX), and the post-PCI absence, compared with the presence, of any untreated lesion with diameter stenosis ≥70% in the LCX was associated with reduced 5-year rates of death or MI (18.9% versus 35.2%; hazard ratio, 0.48 [95% CI, 0.32-0.74]; P<0.001). The risk was the highest for residual ostial/proximal LCX lesions.

Conclusions: Among patients undergoing PCI in EXCEL trial, incomplete revascularization according to the rJS was associated with increased rates of death and spontaneous MI. Post-PCI untreated high-grade lesions in the LCX (especially the ostial/proximal LCX) drove these outcomes.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01205776.

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左心室疾病 PCI 后不完全血管再通的影响：EXCEL试验

背景：左主干冠状动脉疾病患者经皮冠状动脉介入治疗（PCI）后完全血管再通的重要性尚不确定。我们在 EXCEL 试验（评估 XIENCE 与冠状动脉搭桥手术对左主干血管重建效果的影响）中研究了接受 PCI 的左主干冠状动脉疾病患者完全血管重建的临床影响：根据核心实验室对解剖学和功能性完全血管再通的定义、残留的SYNTAX评分（Taxus经皮冠状动脉介入治疗与心脏手术之间的协同作用）和残留的危险评分（rJS），对903名患者进行了为期5年的随访，并对PCI术后死亡或心肌梗死（MI）的综合发生率进行了研究：死亡或心肌梗死的风险并不因解剖、功能或残余 SYNTAX 评分的完全血管再通而不同，但因 rJS 的不同而不同（rJS 0、2 和≥4 的 5 年死亡率分别为 17.6%、19.5% 和 38.9%；P=0.006）。rJS≥4与rJS≤2相比，死亡或心肌梗死率更高，其共同原因是死亡率（调整后危险比，2.29 [95% CI，1.11-4.71]；P=0.02）和自发性心肌梗死（调整后危险比，2.89 [95% CI，1.17-7.17]；P=0.02）增加。rJS≥4组中最常见的未经治疗的严重狭窄部位是左侧环状动脉（LCX），PCI后LCX未出现直径狭窄≥70%的任何未经治疗的病变与5年死亡或心肌梗死发生率降低相关（18.9%对35.2%；危险比为0.48 [95% CI，0.32-0.74]；PC结论：在EXCEL试验中接受PCI治疗的患者中，根据rJS标准进行的不完全血管再通与死亡和自发性心肌梗死的发生率增加有关。PCI后未治疗的LCX（尤其是LCX骨端/近端）高级别病变导致了这些结果：URL：https://www.clinicaltrials.gov；唯一标识符：NCT01205776。

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来源期刊

Circulation: Cardiovascular Interventions CARDIAC & CARDIOVASCULAR SYSTEMS-

CiteScore

10.30

自引率

1.80%

发文量

221

审稿时长

6-12 weeks

期刊介绍： Circulation: Cardiovascular Interventions, an American Heart Association journal, focuses on interventional techniques pertaining to coronary artery disease, structural heart disease, and vascular disease, with priority placed on original research and on randomized trials and large registry studies. In addition, pharmacological, diagnostic, and pathophysiological aspects of interventional cardiology are given special attention in this online-only journal.