Ruel Marc, Kawajiri Hidetake, Glineur David, Grau Juan, Gaudino Mario, Verma Subodh
aDivision of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, CanadabDepartment of Cardiothoracic Surgery, Weill-Cornell Medical Center, New York City, New York, USAcDepartment of Surgery, Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Ontario, Canada.
Curr Opin Cardiol. 2017 Sep;32(5):590-593. doi: 10.1097/HCO.0000000000000434.
Coronary artery bypass grafting (CABG) has been regarded as the mainstream treatment for unprotected left main coronary artery (ULMCA) stenosis. However, the results of the Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial, in which percutaneous coronary intervention (PCI) was deemed noninferior to CABG, have raised a question whether the guidelines should be changed. This article provides a critical appraisal of recent randomized control trials (RCTs) on ULMCA stenosis.
In contrast to EXCEL trial, another large RCT named the Nordic-Baltic-British Left Main Revascularization trial showed that PCI is inferior to CABG in patients treated for ULMCA stenosis. The reason for the discrepancy between these two RCTs may be due to differences in study design. In EXCEL trial, the adoption of new periprocedural myocardial infarction definition, the noninclusion of target vessel revascularization as a primary endpoint component, and the timeline of the study may have helped claim that PCI is noninferior to CABG.
The long-term efficacy of PCI for ULMCA stenosis has not yet been demonstrated. Further studies and follow-up data are needed before the indications for PCI are expanded in this scenario.
冠状动脉旁路移植术（CABG）一直被视为无保护左主干冠状动脉（ULMCA）狭窄的主流治疗方法。然而，在经皮冠状动脉介入治疗（PCI）被认为不劣于CABG的左主干血运重建有效性的XIENCE与冠状动脉旁路手术评估（EXCEL）试验中，其结果引发了指南是否应改变的问题。本文对近期关于ULMCA狭窄的随机对照试验（RCT）进行了批判性评价。
与EXCEL试验不同，另一项名为北欧-波罗的海-英国左主干血运重建试验的大型RCT表明，在接受ULMCA狭窄治疗的患者中，PCI不如CABG。这两项RCT之间存在差异的原因可能是研究设计不同。在EXCEL试验中，采用新的围手术期心肌梗死定义、未将靶血管血运重建作为主要终点组成部分以及研究的时间安排可能有助于宣称PCI不劣于CABG。
PCI治疗ULMCA狭窄的长期疗效尚未得到证实。在此情况下，在扩大PCI适应症之前，需要进一步的研究和随访数据。
