Author + information
- Received October 22, 2018
- Revision received December 7, 2018
- Accepted December 31, 2018
- Published online April 15, 2019.
- Rodrigo Modolo, MDa,b@RodrigoModolo5,
- Ply Chichareon, MDa,c,
- Norihiro Kogame, MDa,
- Ovidiu Dressler, MDd,
- Aaron Crowley, MAd,
- Ori Ben-Yehuda, MDd,
- John Puskas, MDe,
- Adrian Banning, MDf,
- David P. Taggart, MDf,
- A. Pieter Kappetein, MD, PhDg,
- Joseph A. Sabik, MDh,
- Yoshinobu Onuma, MD, PhDi,j,
- Gregg W. Stone, MDk and
- Patrick W. Serruys, MD, PhDl,∗ ()
- aDepartment of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- bDepartment of Internal Medicine, Cardiology Division, University of Campinas (UNICAMP), Campinas, Brazil
- cDivision of Cardiology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
- dCardiovascular Research Foundation, New York, New York
- eMount Sinai Heart at Mount Sinai St. Luke’s, New York, New York
- fOxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- gMedtronic, Dublin, Ireland
- hDepartment of Surgery, UH Cleveland Medical Center, Cleveland, Ohio
- iErasmus Medical Center, Rotterdam, the Netherlands
- jCardialysis Clinical Trials Management and Core Laboratories, Rotterdam, the Netherlands
- kNewYork-Presbyterian Hospital, Columbia University Medical Center, and the Cardiovascular Research Foundation, New York, New York
- lDepartment of Cardiology, Imperial College of London, London, United Kingdom
- ↵∗Address for correspondence:
Prof. Patrick W. Serruys, Erasmus University Medical Center, P.O. Box 2125, 3000 CC Rotterdam, the Netherlands.
Background Although results of percutaneous coronary intervention (PCI) have been steadily improving, whether surgical outcomes have improved over time is not fully elucidated.
Objectives 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.
Methods 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.
Results 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.
Conclusions 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)
The SYNTAX trial was supported by Boston Scientific, and the EXCEL trial was funded by Abbott Vascular. Dr. Modolo has received financial support from Sao Paulo Research Foundation (FAPESP) grant number 2017/22013-8. Dr. Banning has been partially funded by the NHS Oxford NIHR Biomedical Research Centre; has received institutional sponsorship for a fellowship from Boston Scientific; and has received lecture fees from Boston Scientific, Medtronic, and Abbott Vascular. Dr. Puskas has been a consultant to Medtronic. Dr. Kappetein is an employee of Medtronic. Dr. Sabik has been a consultant to Medtronic, Edwards Lifesciences, and Sorin; and has served on an advisory board for Medtronic Cardiac Surgery. Dr. Onuma is an employee of Cardialysis. Dr. Stone has been a consultant to Claret, Backbeat, Sirtex, Matrizyme, Miracor, Neovasc, V-wave, Shockwave, Valfix, TherOx, Reva, Vascular Dynamics, Robocath, HeartFlow, Gore, Ablative Solutions, and Ancora; has received speaker honoraria from Amaranth and Terumo; holds equity in Ancora, Cagent, Qool Therapeutics, Aria, Caliber, Applied Therapeutics, SpectraWave, the MedFocus family of funds, and the BioStar family of funds; is director of SpectraWave; and his employer, Columbia University, receives royalties from sale of the MitraClip manufactured by Abbott Vascular. Prof. Serruys has been a consultant to Abbott, Biosensors, Medtronic, Micell Technologies, QualiMed, SINOMED, St. Jude Medical, Stentys, Svelte, Philips/Volcano, and Xeltis. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Michael J. Mack, MD, served as Guest Associate Editor for this paper.
Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.
- Received October 22, 2018.
- Revision received December 7, 2018.
- Accepted December 31, 2018.
- 2019 American College of Cardiology Foundation
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