Author + information
- Received November 14, 2017
- Revision received November 29, 2017
- Accepted December 8, 2017
- Published online February 12, 2018.
- Ioanna Kosmidou, MD, PhDa,b,
- Shmuel Chen, MDa,
- A. Pieter Kappetein, MD, PhDc,
- Patrick W. Serruys, MD, PhDd,
- Bernard J. Gersh, MB, ChB, DPhile,
- John D. Puskas, MDf,
- David E. Kandzari, MDg,
- David P. Taggart, MDh,
- Marie-Claude Morice, MDi,
- Paweł E. Buszman, MD, PhDj,k,
- Andrzej Bochenek, MDj,k,
- Erick Schampaert, MDl,
- Pierre Pagé, MDl,
- Joseph F. Sabik III, MDm,
- Thomas McAndrew, PhDa,
- Björn Redfors, MD, PhDa,
- Ori Ben-Yehuda, MDa,n and
- Gregg W. Stone, MDa,n,∗ ()
- aClinical Trials Center, Cardiovascular Research Foundation, New York, New York
- bArrhythmia Center, Department of Cardiology, St. Francis Hospital, Roslyn, New York
- cThoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
- dImperial College of Science, Technology and Medicine, London, United Kingdom
- eDepartment of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
- fIcahn School of Medicine at Mount Sinai, New York, New York
- gPiedmont Heart Institute, Atlanta, Georgia
- hDepartment Cardiac Surgery, John Radcliffe Hospital, Oxford, United Kingdom
- iRamsay Générale de Santé, Institut Cardiovasculaire Paris Sud, Paris, France
- jMedical University of Silesia, Katowice, Poland
- kAmerican Heart of Poland, Ustron, Poland
- lHôpital du Sacré-Coeur de Montréal, Montréal, Canada
- mDepartment of Surgery, UH Cleveland Medical Center, Cleveland, Ohio
- nNewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
- ↵∗Address for correspondence:
Dr. Gregg W. Stone, Columbia University Medical Center, Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, New York 10019.
Background There is limited information on the incidence and prognostic impact of new-onset atrial fibrillation (NOAF) following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for left main coronary artery disease (LMCAD).
Objectives This study sought to determine the incidence of NOAF following PCI and CABG for LMCAD and its effect on 3-year cardiovascular outcomes.
Methods In the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, 1,905 patients with LMCAD and low or intermediate SYNTAX scores were randomized to PCI with everolimus-eluting stents versus CABG. Outcomes were analyzed according to the development of NOAF during the initial hospitalization following revascularization.
Results Among 1,812 patients without atrial fibrillation on presentation, NOAF developed at a mean of 2.7 ± 2.5 days after revascularization in 162 patients (8.9%), including 161 of 893 (18.0%) CABG-treated patients and 1 of 919 (0.1%) PCI-treated patients (p < 0.0001). Older age, greater body mass index, and reduced left ventricular ejection fraction were independent predictors of NOAF in patients undergoing CABG. Patients with versus without NOAF had a significantly longer duration of hospitalization, were more likely to be discharged on anticoagulant therapy, and had an increased 30-day rate of Thrombolysis In Myocardial Infarction major or minor bleeding (14.2% vs. 5.5%; p < 0.0001). By multivariable analysis, NOAF after CABG was an independent predictor of 3-year stroke (6.6% vs. 2.4%; adjusted hazard ratio [HR]: 4.19; 95% confidence interval [CI]: 1.74 to 10.11; p = 0.001), death (11.4% vs. 4.3%; adjusted HR: 3.02; 95% CI: 1.60 to 5.70; p = 0.0006), and the primary composite endpoint of death, MI, or stroke (22.6% vs. 12.8%; adjusted HR: 2.13; 95% CI: 1.39 to 3.25; p = 0.0004).
Conclusions In patients with LMCAD undergoing revascularization in the EXCEL trial, NOAF was common after CABG but extremely rare after PCI. The development of NOAF was strongly associated with subsequent death and stroke in CABG-treated patients. Further studies are warranted to determine whether prophylactic strategies to prevent or treat atrial fibrillation may improve prognosis in patients with LMCAD who are undergoing CABG. (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization [EXCEL]; NCT01205776)
- atrial fibrillation
- coronary artery bypass grafting
- left main disease
- percutaneous coronary intervention
The EXCEL trial was funded by Abbott Vascular. Dr. Kappetein is an employee of Medtronic. Dr. Serruys is a consultant for Abbott Laboratories, AstraZeneca Pharmaceuticals, Biotronik, Cardialysis B.V., GLG Research, Medtronic, Sino Medical Sciences Technology, Inc., Société Europa Digital & Publishing, Svelte Medical Systems, Inc., Volcano Europe B.V.B.A., and Q3Medical Devices, Ltd. Dr. Gersh is a consultant for Boston Scientific and Medtronic. Dr. Kandzari has received grant support from Abbott Vascular, Boston Scientific, Medtronic, Biotronik, and Medinol; and is a consultant for Boston Scientific, Medtronic, Micell Technologies, and Biotronik. Dr. Schampaert is a consultant for Abbott Vascular, Boston Scientific, Medtronic, and Philips Medical. Dr. Sabik III is a consultant for Medtronic, Edwards Lifesciences, and Sorin. Dr. Stone’s employer, Columbia University, receives royalties from Abbott Vascular for sale of the MitraClip. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Atul Verma, MD, served as Guest Editor for this paper.
- Received November 14, 2017.
- Revision received November 29, 2017.
- Accepted December 8, 2017.
- 2018 American College of Cardiology Foundation
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