Author + information
- Received August 15, 2019
- Revision received September 4, 2019
- Accepted September 10, 2019
- Published online January 15, 2020.
- Gennaro Giustino, MDa,
- Patrick W. Serruys, MD, PhDb,
- Joseph F. Sabik III, MDc,
- Roxana Mehran, MDa,d,
- Akiko Maehara, MDd,e,
- John D. Puskas, MDf,
- Charles A. Simonton, MDg,
- Nicholas J. Lembo, MDd,e,
- David E. Kandzari, MDh,
- Marie-Claude Morice, MDi,
- David P. Taggart, MD, PhDj,
- Anthony H. Gershlick, MDk,
- Michael Ragosta III, MDl,
- Irving L. Kron, MDl,
- Yangbo Liu, MSd,
- Zixuan Zhang, MSd,
- Thomas McAndrew, PhDd,
- Ovidiu Dressler, MDd,
- Philippe Généreux, MDd,m,n,
- Ori Ben-Yehuda, MDd,e,
- Stuart J. Pocock, PhDo,
- Arie Pieter Kappetein, MD, PhDp and
- Gregg W. Stone, MDa,d,∗ ()
- aThe Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
- bImperial College of Science, Technology and Medicine, London, United Kingdom
- cDepartment of Surgery, UH Cleveland Medical Center, Cleveland, Ohio
- dClinical Trials Center, Cardiovascular Research Foundation, New York, New York
- eNewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
- fMount Sinai Heart at Mount Sinai St Luke’s, New York, New York
- gAbbott Vascular, Santa Clara, California
- hPiedmont Heart Institute, Atlanta, Georgia
- iRamsay Générale de Santé, Hopital Privé Jacques Cartier, Massy, France
- jDepartment Cardiac Surgery, John Radcliffe Hospital, Oxford, United Kingdom
- kUniversity Hospitals of Leicester, Leicester, United Kingdom
- lDivision of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
- mGagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey
- nHôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada
- oDepartment of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
- pErasmus University Medical Center, Rotterdam, the Netherlands
- ↵∗Address for correspondence:
Dr. Gregg W. Stone, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, New York 10019.
Objectives The aim of this study was to investigate the incidence and impact on mortality of repeat revascularization after index percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for left main coronary artery disease (LMCAD).
Background The impact on mortality of the need of repeat revascularization following PCI or CABG in patients with unprotected LMCAD is unknown.
Methods All patients with LMCAD and site-assessed low or intermediate SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) scores randomized to PCI (n = 948) or CABG (n = 957) in the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial were included. Repeat revascularization events were adjudicated by an independent clinical events committee. The effect of repeat revascularization on mortality through 3-year follow-up was examined in time-varying Cox regression models.
Results During 3-year follow-up, there were 346 repeat revascularization procedures among 185 patients. PCI was associated with higher rates of any repeat revascularization (12.9% vs. 7.6%; hazard ratio: 1.73; 95% confidence interval: 1.28 to 2.33; p = 0.0003). Need for repeat revascularization was independently associated with increased risk for 3-year all-cause mortality (adjusted hazard ratio: 2.05; 95% confidence interval: 1.13 to 3.70; p = 0.02) and cardiovascular mortality (adjusted hazard ratio: 4.22; 95% confidence interval: 2.10 to 8.48; p < 0.0001) consistently after both PCI and CABG (pint = 0.85 for both endpoints). Although target vessel revascularization and target lesion revascularization were both associated with an increased risk for mortality, target vessel non–target lesion revascularization and non–target vessel revascularization were not.
Conclusions In the EXCEL trial, repeat revascularization during follow-up was performed less frequently after CABG than PCI and was associated with increased mortality after both procedures. Reducing the need for repeat revascularization may further improve long-term survival after percutaneous or surgical treatment of LMCAD. (EXCEL Clinical Trial; NCT01205776)
The EXCEL trial was sponsored by Abbott Vascular. Dr. Giustino is a consultant for Bristol-Myers Squibb/Pfizer. Dr. Serruys is a consultant for Abbott, Biosensors, Medtronic, Micell, Philips/Volcano, Xeltis, and HeartFlow. Dr. Sabik is a consultant for Medtronic, Technologies, SINOMED Edwards, and Sorin; and is an advisory board member for Medtronic Cardiac Surgery. Dr. Mehran has received institutional research grant support from Eli Lilly/Daiichi Sankyo, Bristol-Myers Squibb, AstraZeneca, The Medicines Company, OrbusNeich, Bayer, CSL Behring, Abbott Laboratories, Watermark Research Partners, Novartis Pharmaceuticals, Medtronic, AUM Cardiovascular, and Beth Israel Deaconess Medical Center; is an executive committee member for Janssen Pharmaceuticals and Osprey Medical; is a data and safety monitoring board member for Watermark Research Partners; is a consultant for Medscape, The Medicines Company, Boston Scientific, Merck, Cardiovascular Systems, Sanofi, Shanghai BraccoSine Pharmaceutical, and AstraZeneca; and holds equity in Claret Medical and Elixir Medical. Dr. Maehara has received institutional grant support from Boston Scientific and Abbott; is a consultant for Boston Scientific and OCT Medical Imaging; and has received speaking fees from Abbott. Dr. Simonton is an employee of Abbott Vascular. Dr. Lembo is a consultant and member of the Speakers Bureau for Abbott Vascular, Boston Scientific, and Medtronic. Dr. Kandzari has received consulting honoraria from Medtronic, Biotronik, and Boston Scientific; and has received research and grant support from Medtronic, Biotronik, and Boston Scientific. Dr. Genereux has received speaking fees from Edwards Lifesciences, Medtronic, Tryton Medical, Cardinal Health, and Cardiovascular Systems; has received consulting fees from Boston Scientific, Cardiovascular Systems, and Pi-Cardia; has received institutional research grant from Boston Scientific; and holds equity in SIG.NUM, SoundBite Medical Solutions, Saranas, and Pi-Cardia. Dr. Pocock is a consultant for Abbott Vascular. Dr. Kappetein is an employee of Medtronic. Dr. Stone has received speaking honoraria from Terumo and Amaranth; and is a consultant to Reva. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 15, 2019.
- Revision received September 4, 2019.
- Accepted September 10, 2019.
- 2020 American College of Cardiology Foundation
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