Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Department of Internal Medicine, Cardiology Division, University of Campinas (UNICAMP), Campinas, Brazil. Electronic address: https://twitter.com/RodrigoModolo5.
Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
J Am Coll Cardiol. 2019 Apr 23;73(15):1877-1886. doi: 10.1016/j.jacc.2018.12.090.
Although results of percutaneous coronary intervention (PCI) have been steadily improving, whether surgical outcomes have improved over time is not fully elucidated.
This study sought to compare the current outcomes of patients undergoing coronary artery bypass grafting (CABG) with prior surgical results, in the context of randomized trials including the left main (LM) coronary artery stem.
The authors performed a propensity-matched analysis of patients randomized to CABG in the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) (enrollment period 2005 to 2007) and EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) (enrollment period 2010 to 2014) trials. All patients had left main (LM) disease with or without multivessel disease. Adjustment was based on 15 clinical and angiographic variables, including anatomic SYNTAX score, with a 2:1 ratio for the EXCEL and SYNTAX trials, collectively analyzing 909 subjects (n = 580 and n = 329, respectively). The primary endpoint was the composite of all-cause death, myocardial infarction (MI), stroke, or ischemia-driven revascularization at 3 years.
Baseline characteristics, anatomic SYNTAX score, number and types of grafts, and duration of hospitalization for the procedures were similar in both groups. CABG procedures in the EXCEL compared with the SYNTAX trial were more often off-pump (29.6% vs. 15.4%; p < 0.001), and guideline-directed medical therapies were used more frequently in the EXCEL surgical cohort. The primary endpoint occurred in 14.0% and 20.9% (p = 0.008) of patients in the EXCEL and SYNTAX trials, respectively. With the exception of MI (4.1% vs. 3.7%), all nonhierarchical events tended to contribute to the improved outcomes in the more recent trial: all-cause death (5.5% vs. 8.5%), stroke (3.1% vs. 5.1%), and ischemia-driven revascularization (7.1% vs. 9.4%) in the EXCEL and SYNTAX trials, respectively.
Over a 5- to 7-year period, significant improvement in event-free survival after surgical revascularization for LM disease at 3 years was noted between the SYNTAX and EXCEL trials, consistent with improving results with cardiac surgery over time. (Synergy Between PCI With Taxus and Cardiac Surgery [SYNTAX]; NCT00114972; Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization [EXCEL]; NCT01205776).
尽管经皮冠状动脉介入治疗（PCI）的结果一直在稳步改善，但手术结果是否随时间推移而改善尚不完全清楚。
本研究旨在比较在包括左主干（LM）冠状动脉干的随机试验中，接受冠状动脉旁路移植术（CABG）的患者目前的手术结果与先前的手术结果，以评估左主干疾病患者接受 PCI 与 CABG 治疗的效果。
作者对接受 SYNTAX（紫杉醇与心脏手术联合 PCI 的协同作用）（登记期 2005 年至 2007 年）和 EXCEL（依维莫司洗脱支架与冠状动脉旁路移植术治疗左主干血运重建效果比较）（登记期 2010 年至 2014 年）试验中随机接受 CABG 的患者进行了倾向匹配分析。所有患者均患有左主干（LM）疾病，伴或不伴多支血管疾病。调整基于 15 项临床和血管造影变量，包括解剖 SYNTAX 评分，EXCEL 和 SYNTAX 试验的比例为 2:1，共分析了 909 例患者（n=580 和 n=329）。主要终点是 3 年时全因死亡、心肌梗死（MI）、卒中和缺血驱动的血运重建的复合终点。
两组患者的基线特征、解剖 SYNTAX 评分、移植血管的数量和类型以及住院时间相似。与 SYNTAX 试验相比，EXCEL 试验中的 CABG 手术更常采用非体外循环（29.6%比 15.4%；p<0.001），并且 EXCEL 手术组更常使用指南推荐的药物治疗。EXCEL 和 SYNTAX 试验中，主要终点的发生率分别为 14.0%和 20.9%（p=0.008）。除 MI（4.1%比 3.7%）外，所有非层次事件均倾向于使最近的试验中出现更好的结果：EXCEL 和 SYNTAX 试验中全因死亡（5.5%比 8.5%）、卒中和缺血驱动的血运重建（7.1%比 9.4%）的发生率均有所降低。
在 5 至 7 年的时间内，SYNTAX 和 EXCEL 试验中 3 年时 LM 疾病患者接受 CABG 治疗后的无事件生存率显著提高，这与随着时间的推移心脏手术结果的改善相一致。（紫杉醇与心脏手术联合 PCI 的协同作用 [SYNTAX]；NCT00114972；依维莫司洗脱支架与冠状动脉旁路移植术治疗左主干血运重建效果比较 [EXCEL]；NCT01205776）。
