Author + information
- Received November 9, 2018
- Revision received May 13, 2019
- Accepted May 29, 2019
- Published online August 5, 2019.
- Umberto Benedetto, MD, PhDa,∗ (, )@UHBristolNHS,
- John Puskas, MDb,
- Arie Pieter Kappetein, MD, PhDc,
- W. Morris Brown III, MDd,
- Ferenc Horkay, MDe,
- Piet W. Boonstra, MDf,
- Gabor Bogáts, MDg,
- Nicolas Noiseux, MDh,
- Ovidiu Dressler, MDi,
- Gianni D. Angelini, MDa,
- Gregg W. Stone, MDi,j@GreggWStone,
- Patrick W. Serruys, MD, PhDk,
- Joseph F. Sabik, MDl and
- David P. Taggart, MD, PhDm
- aUniversity of Bristol, Bristol, United Kingdom
- bMount Sinai Saint Luke's Hospital, New York, New York
- cErasmus University, Rotterdam, the Netherlands
- dPiedmont Atlanta Hospital, Atlanta, Georgia
- eNational Institute of Cardiology, Budapest, Hungary
- fMedisch Centrum Leeuwarden, Leeuwarden, the Netherlands
- gUniversity of Szeged, Szeged, Hungary
- hHôpital Hôtel-Dieu de Montréal, Montréal, Québec, Canada
- iCardiovascular Research Foundation, New York, New York
- jColumbia University Medical Center, New York, New York
- kInternational Centre for Circulatory Health, NHLI, Imperial College London, London, United Kingdom
- lUniversity Hospitals Cleveland Medical Center, Cleveland, Ohio
- mUniversity of Oxford, Oxford, United Kingdom
- ↵∗Address for correspondence:
Dr. Umberto Benedetto, Bristol Heart Institute, University of Bristol, Upper Maudlin Street, Bristol BS2 8HW, United Kingdom.
Background Concerns remain for a greater risk of incomplete revascularization and reduced survival with off-pump coronary artery bypass grafting (CABG) surgery compared with on-pump surgery particularly in patients with left main disease and extensive underlying myocardial ischemia.
Objectives This study sought to compare outcomes following off-pump versus on-pump surgery for left main disease by performing a post hoc analysis from the multicenter, randomized EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial.
Methods The EXCEL trial was designed to compare percutaneous coronary intervention with everolimus-eluting stents versus CABG in patients with left main disease. CABG was performed with or without cardiopulmonary bypass (on-pump vs. off-pump surgery) according to the discretion of the operator. The 3-year outcomes in the off-pump and on-pump groups were compared using inverse probability of treatment weighting (IPTW) for treatment effect estimation.
Results Among 923 CABG patients, 652 and 271 patients underwent on-pump and off-pump surgery, respectively. Despite a similar extent of disease, off-pump surgery was associated with a lower rate of revascularization of the left circumflex coronary artery (84.1% vs. 90.0%; p = 0.01) and right coronary artery (31.1% vs. 40.6%; p = 0.007). After IPTW adjustment for baseline differences, off-pump surgery was associated with a significantly increased risk of 3-year all-cause death (8.8% vs. 4.5%; hazard ratio: 1.94; 95% confidence interval: 1.10 to 3.41; p = 0.02) and a nonsignificant difference in the risk for the composite endpoint of death, myocardial infarction, or stroke (11.8% vs. 9.2%; hazard ratio: 1.28; 95% confidence interval: 0.82 to 2.00; p = 0.28).
Conclusions Among patients with left main disease treated with CABG in the EXCEL trial, off-pump surgery was associated with a lower rate of revascularization of the coronary arteries supplying the inferolateral wall and an increased risk of 3-year all-cause death compared with on-pump surgery.
Dr. Benedetto was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol. Dr. Kappetein is an employee of Medtronic. Dr. Stone has been a consultant to 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/options in Ancora, Cagent, Qool Therapeutics, Aria, Caliber, MedFocus family of funds, Biostar family of funds, Applied Therapeutics, and SpectraWAVE; has served as a director for SpectraWAVE; and his employer, Columbia University, receives royalties for sale of the MitraClip from Abbott. Dr. Sabik has served on a Cardiac Surgery Advisory Board for Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. P.K. Shah, MD, served as Guest Editor-in-Chief for this paper.
Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.
- Received November 9, 2018.
- Revision received May 13, 2019.
- Accepted May 29, 2019.
- 2019 American College of Cardiology Foundation
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