Comparing results of bypass surgery and percutaneous coronary intervention for left main disease by surgical revascularization pump strategyCentral MessagePerspective
Craig M. Jarrett, MD, MBA,
Marc Pelletier, MD,
Yasir Abu-Omar, MD,
Cristian Baeza, MD,
Yakov Elgudin, MD, PhD,
Alan Markowitz, MD,
Zhipeng Zhou, MA,
Björn Redfors, MD, PhD,
Ovidiu Dressler, MD,
Arie Pieter Kappetein, MD, PhD,
Patrick W. Serruys, MD, PhD,
Gregg W. Stone, MD,
Joseph F. Sabik, III, MD
Affiliations
Craig M. Jarrett, MD, MBA
Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
Marc Pelletier, MD
Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
Yasir Abu-Omar, MD
Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
Cristian Baeza, MD
Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
Yakov Elgudin, MD, PhD
Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
Alan Markowitz, MD
Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
Zhipeng Zhou, MA
Clinical Trials Center, Cardiovascular Research Foundation, New York, NY
Björn Redfors, MD, PhD
Clinical Trials Center, Cardiovascular Research Foundation, New York, NY; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
Ovidiu Dressler, MD
Clinical Trials Center, Cardiovascular Research Foundation, New York, NY
Arie Pieter Kappetein, MD, PhD
Department of Cardio-Thoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
Patrick W. Serruys, MD, PhD
Department of Cardiology, NUIG, National University of Ireland, Galway, Ireland; Interventional Department, Imperial College of Science, Technology and Medicine, London, United Kingdom
Gregg W. Stone, MD
The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
Joseph F. Sabik, III, MD
Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio; Address for reprints: Joseph F. Sabik III, MD, Department of Surgery, University Hospitals Cleveland Medical Center, Lakeside 7th Floor, 11100 Euclid Ave, Cleveland, OH 44106.
Objective: We performed a post hoc analysis of the Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial to determine the effect an on-versus off-pump strategy had on outcomes when compared with percutaneous coronary intervention. Methods: All randomized patients in EXCEL (n = 1905) were included. The outcomes of interest were the primary end point composite of death from any cause, stroke, or myocardial infarction; the composite study end point or ischemia-driven revascularization; and the rate of death from any cause at 5 years. Event rates were based on Kaplan–Meier estimates in time-to-first-event analyses. Results: Propensity matching resulted in groups of 1142 patients (571 each) for on-pump coronary artery bypass grafting versus percutaneous coronary intervention and 472 patients (236 each) for off-pump coronary artery bypass grafting versus percutaneous coronary intervention. In the on-pump coronary artery bypass grafting versus percutaneous coronary intervention matched groups, the composite end point was similar (18.0% vs 22.1%, P = .19) and the composite end point or ischemia-driven revascularization (23.3% vs 31.0%, P = .01) was lower, and mortality (7.6% vs 11.8%, P = .025) was lower in the on-pump coronary artery bypass grafting group at 5 years. In the off-pump coronary artery bypass grafting versus percutaneous coronary intervention matched groups, the composite end point (19.4% vs 22.2%, P = .47), composite end point or ischemia-driven revascularization (25.9% vs 34.2%, P = .07), and mortality (12.5% vs 14.2%, P = .59) were similar at 5 years. Conclusions: In the EXCEL trial, on-pump coronary artery bypass grafting was associated with a decreased 5-year rate of the composite outcome of death, stroke, myocardial infarction, or ischemia-driven revascularization, and decreased mortality when compared with percutaneous coronary intervention, whereas outcomes of off-pump coronary artery bypass grafting were similar to percutaneous coronary intervention.
