JTCVS Open (Dec 2023)

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

Journal volume & issue
Vol. 16
pp. 372 – 388

Abstract

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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.

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