Impact of large periprocedural myocardial infarction on mortality after percutaneous coronary intervention and coronary artery bypass grafting for left main disease: an analysis from the EXCEL trial. (28th March 2019)

• Record Type: Journal Article
• Authors: Ben-Yehuda, Ori; Chen, Shmuel; Redfors, Björn; McAndrew, Thomas; Crowley, Aaron; Kosmidou, Ioanna; Kandzari, David E; Puskas, John D; Morice, Marie-Claude; Taggart, David P; Leon, Martin B; Lembo, Nicholas J; Brown, W Morris; Simonton, Charles A; Dressler, Ovidiu; Kappetein, Arie Pieter; Sabik, Joseph F; Serruys, Patrick W; Stone, Gregg W
• Is Part Of: European heart journal. Volume 40:Number 24(2019)
• Page Start: 1930
• Page End: 1941
• Publication Date: 2019-03-28
• Subjects: Left main coronary artery -- Periprocedural myocardial infarction -- Percutaneous coronary intervention -- Coronary artery bypass grafting -- Revascularization; Cardiology -- Periodicals; Heart -- Diseases -- Periodicals; 616.12005
• DOI: 10.1093/eurheartj/ehz113
• Languages: English
• ISSNs: 0195-668X

Abstract

Abstract: Aims: The prognostic implications of periprocedural myocardial infarction (PMI) after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) remain controversial. We examined the 3-year rates of mortality among patients with and without PMI undergoing left main coronary artery intervention randomized to PCI with everolimus-eluting stents vs. CABG in the large-scale, multicentre, prospective, randomized EXCEL trial. Methods and results: By protocol, PMI was defined using an identical threshold for PCI and CABG [creatinine kinase-MB (CK-MB) elevation >10× the upper reference limit (URL) within 72 h post-procedure, or >5× URL with new Q-waves, angiographic vessel occlusion, or loss of myocardium on imaging]. Cox proportional hazards modelling was performed controlling for age, sex, hypertension, diabetes mellitus, left ventricular ejection fraction, SYNTAX score, and chronic obstructive pulmonary disease (COPD). A total of 1858 patients were treated as assigned by randomization. Periprocedural MI occurred in 34/935 (3.6%) of patients in the PCI group and 56/923 (6.1%) of patients in the CABG group [odds ratio 0.61, 95% confidence interval (CI) 0.40–0.93; P = 0.02]. Periprocedural MI was associated with SYNTAX score, COPD, cross-clamp duration and total procedure duration, and not using antegrade cardioplegia. By multivariable analysis, PMI was associated with cardiovascular death and all-cause death at 3 years [adjusted hazard ratio (HR) 2.63, 95% CI 1.19–5.81; P = 0.02 and adjusted HR 2.28, 95% CI 1.22–4.29; P = 0.01, respectively]. The effect of PMI was consistent for PCI and CABG for cardiovascular death ( P interaction = 0.56) and all-cause death ( P interaction = 0.59). Peak post-procedure CK-MB ≥10× URL strongly predicted mortality, whereas lesser degrees of myonecrosis were not associated with prognosis. Conclusion: In the EXCEL trial, PMI was more common after CABG than PCI, and was strongly associated with increased 3-year mortality after controlling for potential confounders. Only extensive myonecrosis (CK-MB ≥10× URL) was prognostically important.