左主干病变 PCI 后不完全血运重建的影响：EXCEL 试验。
Impact of Incomplete Revascularization After PCI in Left Main Disease: The EXCEL Trial.
机构信息
Cardiovascular Research Foundation, New York, NY (Z.A.A., J.J.G., J.H., A.G., O.B.-Y., B.R.).
St Francis Hospital and Heart Center, Roslyn, NY (Z.A.A., K.K.G., D.S.).
出版信息
Circ Cardiovasc Interv. 2024 Mar;17(3):e013192. doi: 10.1161/CIRCINTERVENTIONS.123.013192. Epub 2024 Mar 19.
BACKGROUND
The importance of complete revascularization after percutaneous coronary intervention (PCI) in patients with left main coronary artery disease is uncertain. We investigated the clinical impact of complete revascularization in patients with left main coronary artery disease undergoing PCI in the EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization).
METHODS
Composite rates of death or myocardial infarction (MI) following PCI during 5-year follow-up were examined in 903 patients based on core laboratory definitions of anatomic and functional complete revascularization, residual SYNTAX score (The Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery), and residual Jeopardy Score (rJS).
RESULTS
The risk of death or MI did not vary based on anatomic, functional, or residual SYNTAX score complete revascularization but did differ according to the rJS (5-year rates 17.6%, 19.5%, and 38.9% with rJS 0, 2, and ≥4, respectively; =0.006). The higher rate of death or MI with rJS≥4 versus rJS≤2 was driven conjointly by increased mortality (adjusted hazard ratio, 2.29 [95% CI, 1.11-4.71]; =0.02) and spontaneous MI (adjusted hazard ratio, 2.89 [95% CI, 1.17-7.17]; =0.02). The most common location for untreated severe stenoses in the rJS≥4 group was the left circumflex artery (LCX), and the post-PCI absence, compared with the presence, of any untreated lesion with diameter stenosis ≥70% in the LCX was associated with reduced 5-year rates of death or MI (18.9% versus 35.2%; hazard ratio, 0.48 [95% CI, 0.32-0.74]; <0.001). The risk was the highest for residual ostial/proximal LCX lesions.
CONCLUSIONS
Among patients undergoing PCI in EXCEL trial, incomplete revascularization according to the rJS was associated with increased rates of death and spontaneous MI. Post-PCI untreated high-grade lesions in the LCX (especially the ostial/proximal LCX) drove these outcomes.
REGISTRATION
URL: https://www.clinicaltrials.gov; Unique identifier: NCT01205776.
背景
经皮冠状动脉介入治疗（PCI）后完全血运重建对左主干冠状动脉疾病患者的重要性尚不确定。我们在 EXCEL 试验（XIENCE 与冠状动脉旁路移植术治疗左主干血运重建效果评估）中调查了接受 PCI 的左主干冠状动脉疾病患者完全血运重建的临床影响。
方法
根据解剖学和功能完全血运重建、残余 SYNTAX 评分（经皮冠状动脉介入治疗与 Taxus 之间的协同作用与心脏手术）和残余危险评分（rJS）的核心实验室定义，在 903 例患者中检查了 PCI 后 5 年随访期间死亡或心肌梗死（MI）的复合发生率。
结果
死亡或 MI 的风险与解剖学、功能或残余 SYNTAX 评分完全血运重建无关，但与 rJS 相关（rJS 为 0、2 和≥4 时的 5 年发生率分别为 17.6%、19.5%和 38.9%；=0.006）。rJS≥4 与 rJS≤2 相比，死亡或 MI 发生率较高，这主要是由于死亡率增加（调整后的危险比，2.29[95%CI，1.11-4.71]；=0.02）和自发性 MI（调整后的危险比，2.89[95%CI，1.17-7.17]；=0.02）。rJS≥4 组中未经治疗的严重狭窄最常见的部位是左回旋支（LCX），与 LCX 中任何未经治疗的直径狭窄≥70%的病变相比，PCI 后不存在未经治疗的病变与降低 5 年死亡或 MI 发生率相关（18.9%与 35.2%；危险比，0.48[95%CI，0.32-0.74]；<0.001）。残余开口/近段 LCX 病变的风险最高。
结论
在 EXCEL 试验中接受 PCI 的患者中，根据 rJS 不完全血运重建与死亡率和自发性 MI 发生率增加相关。PCI 后 LCX 中的未经治疗的高级病变（尤其是开口/近段 LCX）导致了这些结果。
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