根据病变部位比较经皮冠状动脉介入治疗与冠状动脉旁路移植术治疗左主干病变的结果：EXCEL 试验结果。
Outcomes After Left Main Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting According to Lesion Site: Results From the EXCEL Trial.
机构信息
University Hospitals of Leicester, University of Leicester, Leicester Biomedical Research Centre, Leicester, United Kingdom.
Piedmont Heart Institute, Atlanta, Georgia.
出版信息
JACC Cardiovasc Interv. 2018 Jul 9;11(13):1224-1233. doi: 10.1016/j.jcin.2018.03.040.
OBJECTIVES
The authors sought to determine the extent to which the site of the left main coronary artery (LM) lesion (distal bifurcation versus ostial/shaft) influences the outcomes of revascularization with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG).
BACKGROUND
Among 1,905 patients with LM disease and site-assessed SYNTAX scores of <32 randomized in the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, revascularization with PCI and CABG resulted in similar rates of the composite primary endpoint of death, myocardial infarction (MI), or stroke at 3 years.
METHODS
Outcomes from the randomized EXCEL trial were analyzed according to the presence of angiographic core laboratory-determined diameter stenosis ≥50% involving the distal LM bifurcation (n = 1,559; 84.2%) versus disease isolated to the LM ostium or shaft (n = 293; 15.8%).
RESULTS
At 3 years, there were no significant differences between PCI and CABG for the primary composite endpoint of death, MI, or stroke for treatment of both distal LM bifurcation disease (15.6% vs. 14.9%, odds ratio [OR]: 1.08, 95% confidence interval [CI]: 0.81 to 1.42; p = 0.61) and isolated LM ostial/shaft disease (12.4% vs. 13.5%, OR: 0.90, 95% CI: 0.45 to 1.81; p = 0.77) (p = 0.65). However, at 3 years, ischemia-driven revascularization occurred more frequently after PCI than CABG in patients with LM distal bifurcation disease (13.0% vs. 7.2%, OR: 2.00, 95% CI: 1.41 to 2.85; p = 0.0001), but were not significantly different in patients with disease only at the LM ostium or shaft (9.7% vs. 8.4%, OR: 1.18, 95% CI: 0.52 to 2.69; p = 0.68) (p = 0.25).
CONCLUSIONS
In the EXCEL trial, PCI and CABG resulted in comparable rates of death, MI, or stroke at 3 years for treatment of LM disease, including those with distal LM bifurcation disease. Repeat revascularization rates during follow-up after PCI compared with CABG were greater for lesions in the distal LM bifurcation but were similar for disease isolated to the LM ostium or shaft.
目的
作者旨在确定左主干冠状动脉（LM）病变部位（远端分叉与开口/主干）对经皮冠状动脉介入治疗（PCI）与冠状动脉旁路移植术（CABG）血运重建结果的影响程度。
背景
在 EXCEL（评价 XIENCE 与 CABG 治疗左主干血运重建效果的 SYNTAX 评分）试验中，1905 例 LM 疾病患者和 SYNTAX 评分<32 分的患者进行了随机分组，其中 1559 例（84.2%）存在由血管造影核心实验室确定的直径狭窄≥50%的远端 LM 分叉病变，293 例（15.8%）病变局限于 LM 开口或主干。
方法
根据是否存在由血管造影核心实验室确定的直径狭窄≥50%的远端 LM 分叉病变（n=1559；84.2%）或病变仅局限于 LM 开口或主干（n=293；15.8%），对随机分组的 EXCEL 试验结果进行分析。
结果
3 年时，对于远端 LM 分叉病变（15.6% vs. 14.9%，比值比[OR]：1.08，95%置信区间[CI]：0.81 至 1.42；p=0.61）和孤立性 LM 开口/主干病变（12.4% vs. 13.5%，OR：0.90，95%CI：0.45 至 1.81；p=0.77），PCI 与 CABG 治疗远端 LM 分叉病变和孤立性 LM 开口/主干病变的主要复合终点（死亡、心肌梗死[MI]或卒中）无显著差异（p=0.65）。然而，3 年时，对于存在远端 LM 分叉病变的患者，与 CABG 相比，PCI 后缺血驱动的血运重建更频繁（13.0% vs. 7.2%，OR：2.00，95%CI：1.41 至 2.85；p=0.0001），但对于仅存在 LM 开口或主干病变的患者，两组间无显著差异（9.7% vs. 8.4%，OR：1.18，95%CI：0.52 至 2.69；p=0.68）（p=0.25）。
结论
在 EXCEL 试验中，对于 LM 疾病（包括存在远端 LM 分叉病变的患者）的治疗，PCI 和 CABG 导致 3 年时的死亡率、MI 或卒中发生率相似。与 CABG 相比，PCI 后再次血运重建的比率在远端 LM 分叉病变中更高，但在仅存在 LM 开口或主干病变的患者中相似。
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