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Giustino G, Serruys PW, Sabik JF, Mehran R, Maehara A, Puskas JD, Simonton CA, Lembo NJ, Kandzari DE, Morice MC, Taggart DP, Gershlick AH, Ragosta M, Kron IL, Liu Y, Zhang Z, McAndrew T, Dressler O, Généreux P, Ben-Yehuda O, Pocock SJ, Kappetein AP, Stone GW. Mortality After Repeat Revascularization Following PCI or CABG for Left Main Disease: The EXCEL Trial. JACC Cardiovasc Interv 2020; 13:375-387. [PMID: 31954680 DOI: 10.1016/j.jcin.2019.09.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 09/04/2019] [Accepted: 09/10/2019] [Indexed: 10/25/2022]
Abstract
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).
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Affiliation(s)
- Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Patrick W Serruys
- Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Joseph F Sabik
- Department of Surgery, UH Cleveland Medical Center, Cleveland, Ohio
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Akiko Maehara
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - John D Puskas
- Mount Sinai Heart at Mount Sinai St Luke's, New York, New York
| | | | - Nicholas J Lembo
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | | | | | - David P Taggart
- Department Cardiac Surgery, John Radcliffe Hospital, Oxford, United Kingdom
| | | | - Michael Ragosta
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Irving L Kron
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Yangbo Liu
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Zixuan Zhang
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Thomas McAndrew
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Ovidiu Dressler
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Philippe Généreux
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey; Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada
| | - Ori Ben-Yehuda
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York.
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Fukui T, Takanashi S. Acute Coronary Syndrome Does Not Have a Negative Impact on Outcomes after Coronary Artery Bypass Grafting in Patients with Left Main Disease. Ann Thorac Cardiovasc Surg 2015; 21:261-7. [PMID: 25641028 PMCID: PMC4989973 DOI: 10.5761/atcs.oa.14-00228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 09/18/2014] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Early and long-term outcomes of coronary artery bypass grafting (CABG) in patients with left main disease (LMD) with acute coronary syndrome (ACS) have never been assessed. METHODS Between September 2004 and April 2012, 459 patients with LMD underwent first-time isolated CABG. Of those, 191 patients had ACS and 268 did not. Early and late postoperative outcomes were compared between two groups. RESULTS Patients in the LMD+ACS group were older and more likely to be female. Left ventricular ejection fraction was lower in the LMD+ACS group. In both groups, bilateral internal thoracic artery grafts were used in over 90% of patients and off-pump technique in over 95%. Operative death rate was not significantly different between the groups (LMD+ACS: 2.1% vs. LMD-ACS 0.4%). Log-rank test revealed that the actuarial survival rate (79.2 ± 3.7% vs. 81.5 ± 3.5%) and freedom from major adverse cardiac and cerebrovascular events (MACCE) (69.2 ± 4.2% vs. 67.0 ± 4.1%) were similar between groups at 7 years. Multivariate analyses demonstrated that ACS was not identified as an independent predictor of operative death, late mortality, and late MACCE. CONCLUSION ACS did not have a negative impact on early and late outcomes of CABG in patients with LMD.
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Affiliation(s)
- Toshihiro Fukui
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
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Chakrabarti AK, Grau-Sepulveda MV, O'Brien S, Abueg C, Ponirakis A, Delong E, Peterson E, Klein LW, Garratt KN, Weintraub WS, Gibson CM. Angiographic validation of the American College of Cardiology Foundation-the Society of Thoracic Surgeons Collaboration on the Comparative Effectiveness of Revascularization Strategies study. Circ Cardiovasc Interv 2014; 7:11-8. [PMID: 24496239 DOI: 10.1161/circinterventions.113.000679] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The goal of this study was to compare angiographic interpretation of coronary arteriograms by sites in community practice versus those made by a centralized angiographic core laboratory. METHODS AND RESULTS The study population consisted of 2013 American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) records with 2- and 3- vessel coronary disease from 54 sites in 2004 to 2007. The primary analysis compared Registry (NCDR)-defined 2- and 3-vessel disease versus those from an angiographic core laboratory analysis. Vessel-level kappa coefficients suggested moderate agreement between NCDR and core laboratory analysis, ranging from kappa=0.39 (95% confidence intervals, 0.32-0.45) for the left anterior descending artery to kappa=0.59 (95% confidence intervals, 0.55-0.64) for the right coronary artery. Overall, 6.3% (n=127 out of 2013) of those patients identified with multivessel disease at NCDR sites had had 0- or 1-vessel disease by core laboratory reading. There was no directional bias with regard to overcall, that is, 12.3% of cases read as 3-vessel disease by the sites were read as <3-vessel disease by the core laboratory, and 13.9% of core laboratory 3-vessel cases were read as <3-vessel by the sites. For a subset of patients with left main coronary disease, registry overcall was not linked to increased rates of mortality or myocardial infarction. CONCLUSIONS There was only modest agreement between angiographic readings in clinical practice and those from an independent core laboratory. Further study will be needed because the implications for patient management are uncertain.
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Affiliation(s)
- Anjan K Chakrabarti
- From the Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (A.K.C., C.M.G.); PERFUSE Angiographic Core Laboratories and Data Coordinating Center, Beth Israel Deaconess Medical Center, Boston, MA (A.K.C., C.A., C.M.G.); Duke Clinical Research Institute, Duke University, Durham, NC (M.V.G.-S., S.O., E.D., E.P.); American College of Cardiology, Washington, DC (A.P.); Division of Internal Medicine, Department of Medicine, Rush University, Chicago, IL (L.W.K.); Northshore-LIJ/Lenox Hill Hospital, New York, NY (K.N.G.); and Christiana Care Health System, Newark, DE (W.S.W.)
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Golmohamadi Z, Sokhanvar S, Aslanabadi N, Ghaffari S, Sohrabi B. One-Year Outcomes After Everolimus-Eluting Stents Implantation in Ostial Lesions of Left Anterior Descending Coronary Arteries. Cardiol Res 2013; 4:192-198. [PMID: 28352444 PMCID: PMC5358308 DOI: 10.4021/cr295w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2013] [Indexed: 11/30/2022] Open
Abstract
Background In recent years, stents are increasingly used in variety of coronary lesions. Ostial lesion of left anterior descending coronary artery (LAD) however remains a challenge area because of the invariable involvement of distal left main coronary artery (LMCA). This study was designed to evaluate the clinical and angiographic outcomes of everolimus-eluting stent (EES) implantation for ostial LAD. Methods EESs were implanted in 45 consecutive patients with ostial LAD stenoses. For complete lesion coverage, stent positing was extended into the distal LMCA in 6 patients (13.3%) with intermediated LMCA narrowing. We assess MACE during one-year follow-up. Results In-hospital success rate was 100%; neither cardiac death nor stent thrombosis in our patients, but two patients had myocardial infarction in non-related coronary artery during follow-up. Two patients had angiographic restenosis and underwent TLR. The cumulative MACE-free survival rate was 95.6% at one year. Conclusion EES was in ostial LAD lesions with complete lesion coverage achieving high procedural success rate and acceptable clinical outcomes during one-year follow-up period.
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Affiliation(s)
- Zahra Golmohamadi
- Cardiovascular Research Center, Shaheed Madani Heart Hospital, Medical Science University, Tabriz, Iran
| | - Sepideh Sokhanvar
- Ayatollah Mosavi Cardiology Department, Medical Science University, Zanjan, Iran
| | - Naser Aslanabadi
- Cardiovascular Research Center, Shaheed Madani Heart Hospital, Medical Science University, Tabriz, Iran
| | - Samad Ghaffari
- Cardiovascular Research Center, Shaheed Madani Heart Hospital, Medical Science University, Tabriz, Iran
| | - Bahram Sohrabi
- Cardiovascular Research Center, Shaheed Madani Heart Hospital, Medical Science University, Tabriz, Iran
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Abstract
In the tradition of Dr Arom, who had many interests in his clinical and research career, I will touch on three things that will impact the practice of clinical cardiac surgery over the next several years: use of bilateral internal mammary arteries, use of external mesh support to improve saphenous vein graft patency, and anticoagulation of mechanical heart valves. The remainder of the presentation goes into depth on the development of a bloodless heart surgery program, which is contemporary and timely as it encompasses some thoughts of this society.
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Emery RW, Cooper MM, Joyce DL. Over the Next Hill. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2012. [DOI: 10.1177/155698451200700302] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Robert W. Emery
- HealthEast Care System, Saint Joseph's Hospital, St Paul, MN USA
| | | | - David L. Joyce
- HealthEast Care System, Saint Joseph's Hospital, St Paul, MN USA
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Arnold SV, Magnuson EA, Wang K, Serruys PW, Kappetein AP, Mohr FW, Cohen DJ. Do differences in repeat revascularization explain the antianginal benefits of bypass surgery versus percutaneous coronary intervention?: implications for future treatment comparisons. Circ Cardiovasc Qual Outcomes 2012; 5:267-75. [PMID: 22496114 DOI: 10.1161/circoutcomes.111.964585] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with multivessel coronary disease treated with coronary artery bypass graft (CABG) have less angina than those treated with percutaneous coronary intervention (PCI); however, there is uncertainty as to the mechanism of greater angina relief with CABG and whether more frequent repeat revascularization in patients treated with PCI could account for this treatment difference. METHODS AND RESULTS In the Synergy between percutaneous coronary intervention (PCI) with TAXUS and Cardiac Surgery trial, 1800 patients with 3-vessel or left main coronary artery disease were randomized to CABG or PCI with paclitaxel-eluting stents. Health status was assessed at baseline, 1, 6, and 12 months, using the Seattle Angina Questionnaire and the Medical Outcomes Study Short Form General Health Survey, and the association between repeat revascularization and health status during follow-up was assessed using longitudinal models. In adjusted analyses, patients who underwent repeat revascularization had worse angina frequency scores than patients who did not in both treatment groups, with differences of 8.5 points at 6 months and 3.1 points at 12 months in patients treated with PCI and 19.8 points at 6 months and 11.2 points at 12 months in patients with patients treated with CABG. Among patients who did not require repeat revascularization, the adjusted effect of CABG versus PCI on 12-month angina frequency scores was nearly identical to the overall benefit in the intention-to-treat analysis. CONCLUSIONS Among patients with multivessel coronary artery disease treated with PCI or CABG, the occurrence of repeat revascularization during follow-up did not fully explain the antianginal benefit of CABG in the overall population. The differential association between repeat revascularization and anginal status, according to the type of initial revascularization procedure, suggests that this end point should play a limited role in any direct comparison of the 2 treatment strategies.
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Affiliation(s)
- Suzanne V Arnold
- St. Luke's Mid America Heart Institute, Kansas City, MO 64111, USA
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Singh IM, Holmes DR. Myocardial Revascularization by Percutaneous Coronary Intervention: Past, Present, and the Future. Curr Probl Cardiol 2011; 36:375-401. [DOI: 10.1016/j.cpcardiol.2011.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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De Luca L, Altamura L, Corvo P, De Persio G, Ghini AS, Petrolini A, Aurigemma C, Tomai F. Long-term outcome of provisional side-branch T-stenting for the treatment of unprotected distal left main coronary artery disease. Catheter Cardiovasc Interv 2011; 77:765-72. [DOI: 10.1002/ccd.22899] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Accepted: 10/26/2010] [Indexed: 11/06/2022]
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Fukui T, Tabata M, Manabe S, Shimokawa T, Shimizu J, Morita S, Takanashi S. Off-pump bilateral internal thoracic artery grafting in patients with left main disease. J Thorac Cardiovasc Surg 2010; 140:1040-5. [DOI: 10.1016/j.jtcvs.2009.11.069] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Revised: 11/02/2009] [Accepted: 11/27/2009] [Indexed: 10/19/2022]
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Capranzano P, Sanfilippo A, Tagliareni F, Capodanno D, Monaco S, Sardella G, Giordano A, Sangiorgi GM, Tamburino C. Long-term outcomes after drug-eluting stent for the treatment of ostial left anterior descending coronary artery lesions. Am Heart J 2010; 160:973-8. [PMID: 21095288 DOI: 10.1016/j.ahj.2010.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Accepted: 07/02/2010] [Indexed: 11/24/2022]
Abstract
BACKGROUND Although drug-eluting stents (DES) have reduced restenosis in a broad range of lesions, there is limited data, from relatively small studies, on the safety and efficacy of DES for isolated ostial left anterior descending (LAD) stenoses. In addition, in the setting of these high-risk lesions, there is the issue of the potential involvement of the left main (LM) bifurcation, requiring subsequent revascularization for a lesion involving this critical location. METHODS Patients with a de novo isolated unprotected ostial LAD stenoses treated with DES were included. Evaluated end points were cardiac death, nonfatal myocardial infarction, overall target lesion revascularization (TLR), and the reintervention for a restenotic lesion located at the LM segment adjacent to the stent (TLR-LM). RESULTS A total of 162 patients were included: 95 underwent focal ostial LAD stenting and 67 stenting from the distal LM into the LAD ostium. The 2-year Kaplan-Meier estimates of cardiac death, nonfatal myocardial infarction, overall TLR, and TLR-LM were 2.6%, 2.1%, 8.3%, and 4.7%, respectively. Overall TLR and TLR-LM rates were higher in the focal ostial LAD stenting group. There was a trend toward an independent increased risk of TLR associated with focal ostial stenting. In addition, final minimal luminal diameter trended to be independently associated with TLR. CONCLUSION The present study showed that DES for isolated ostial LAD lesions is a feasible, safe, and effective treatment strategy. In addition, this study suggested the hypothesis that a default distal LM-LAD stenting, rather than focal ostial stenting, might provide more favorable outcomes. Nevertheless, larger specifically designed studies are needed.
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Tamburino C, Capranzano P, Capodanno D, Tagliareni F, Biondi-Zoccai G, Sanfilippo A, Caggegi A, Barrano G, Monaco S, Tomasello SD, La Manna A, Di Salvo M, Sheiban I. Plaque Distribution Patterns in Distal Left Main Coronary Artery to Predict Outcomes After Stent Implantation. JACC Cardiovasc Interv 2010; 3:624-31. [PMID: 20630455 DOI: 10.1016/j.jcin.2010.03.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2009] [Revised: 02/25/2010] [Accepted: 03/26/2010] [Indexed: 02/05/2023]
Affiliation(s)
- Corrado Tamburino
- Cardiovascular Department, Ferrarotto Hospital, University of Catania, Catania, Italy
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Health-Related Quality of Life Following Carotid Stenting Versus Endarterectomy. JACC Cardiovasc Interv 2010; 3:515-23. [DOI: 10.1016/j.jcin.2010.02.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2009] [Revised: 02/16/2010] [Accepted: 02/21/2010] [Indexed: 11/19/2022]
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Kaul S, Diamond GA. Trial and Error. J Am Coll Cardiol 2010; 55:415-27. [PMID: 20117454 DOI: 10.1016/j.jacc.2009.06.065] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2009] [Revised: 06/01/2009] [Accepted: 06/01/2009] [Indexed: 10/19/2022]
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Edris A, Patel PM, Kern MJ. Early recognition of catheter-induced left main coronary artery vasospasm: Implications for revascularization. Catheter Cardiovasc Interv 2010; 76:304-7. [DOI: 10.1002/ccd.22462] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Kandzari DE, Colombo A, Park SJ, Tommaso CL, Ellis SG, Guzman LA, Teirstein PS, Tamburino C, Ormiston J, Stone GW, Dangas GD, Popma JJ, Bass TA. Revascularization for Unprotected Left Main Disease. J Am Coll Cardiol 2009; 54:1576-88. [PMID: 19833256 DOI: 10.1016/j.jacc.2009.07.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2009] [Revised: 07/13/2009] [Accepted: 07/21/2009] [Indexed: 11/26/2022]
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Treatment selection for coronary artery disease: The collision of a belief system with evidence. J Thorac Cardiovasc Surg 2009; 137:1050-3. [DOI: 10.1016/j.jtcvs.2009.03.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2009] [Revised: 03/09/2009] [Accepted: 03/10/2009] [Indexed: 11/21/2022]
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Smith PK. Treatment selection for coronary artery disease: the collision of a belief system with evidence. Ann Thorac Surg 2009; 87:1328-31. [PMID: 19379858 DOI: 10.1016/j.athoracsur.2009.03.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2009] [Revised: 03/09/2009] [Accepted: 03/10/2009] [Indexed: 11/29/2022]
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