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Kosmidou I, Shahim B, Dressler O, Redfors B, Morice MC, Puskas JD, Kandzari DE, Karmpaliotis D, Brown WM, Lembo NJ, Banning AP, Kappetein AP, Serruys PW, Sabik JF, Stone GW. Incidence, Predictors, and Impact of Hospital Readmission After Revascularization for Left Main Coronary Disease. J Am Coll Cardiol 2024; 83:1073-1081. [PMID: 38479955 DOI: 10.1016/j.jacc.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/14/2023] [Accepted: 01/03/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND The frequency of and relationship between hospital readmissions and outcomes after revascularization for left main coronary artery disease (LMCAD) are unknown. OBJECTIVES The purpose of this study was to study the incidence, predictors, and clinical impact of readmissions following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for LMCAD. METHODS In the EXCEL (XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, 1,905 patients with LMCAD were randomized to PCI vs CABG. The cumulative incidence of readmissions was analyzed with multivariable Anderson-Gill and joint frailty models to account for recurrent events and the competing risk of death. The impact of readmission on subsequent mortality within 5-year follow-up was determined in a time-adjusted Cox proportional hazards model. RESULTS Within 5 years, 1,868 readmissions occurred in 851 of 1,882 (45.2%) hospital survivors (2.2 ± 1.9 per patient with readmission[s], range 1-16), approximately one-half for cardiovascular causes and one-half for noncardiovascular causes (927 [49.6%] and 941 [50.4%], respectively). One or more readmissions occurred in 463 of 942 (48.6%) PCI patients vs 388 of 940 (41.8%) CABG patients (P = 0.003). After multivariable adjustment, PCI remained an independent predictor of readmission (adjusted HR: 1.22; 95% CI: 1.10-1.35; P < 0.0001), along with female sex, comorbidities, and the extent of CAD. Readmission was independently associated with subsequent all-cause death, with interaction testing indicating a higher risk after PCI than CABG (adjusted HR: 5.72; 95% CI: 3.42-9.55 vs adjusted HR: 2.72; 95% CI: 1.64-4.88, respectively; Pint = 0.03). CONCLUSIONS In the EXCEL trial, readmissions during 5-year follow-up after revascularization for LMCAD were common and more frequent after PCI than CABG. Readmissions were associated with an increased risk of all-cause death, more so after PCI than with CABG.
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Affiliation(s)
- Ioanna Kosmidou
- Memorial Sloan Kettering Cancer Center, New York and Weill Cornell College of Medicine, New York, New York, USA; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Bahira Shahim
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Ovidiu Dressler
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - John D Puskas
- Mount Sinai Heart at Mount Sinai Saint Luke's, New York, New York, USA
| | | | - Dimitri Karmpaliotis
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | | | - Nicholas J Lembo
- Memorial Sloan Kettering Cancer Center, New York and Weill Cornell College of Medicine, New York, New York, USA; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | | | | | - Patrick W Serruys
- Department of Cardiology, NUIG, National University of Ireland, Galway, Ireland; Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Joseph F Sabik
- Department of Surgery, UH Cleveland Medical Center, Cleveland, Ohio, USA
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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2
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Gaudino M, Flather M, Capodanno D, Milojevic M, Bhatt DL, Biondi Zoccai G, Boden WE, Devereaux PJ, Doenst T, Farkouh M, Freemantle N, Fremes S, Puskas J, Landoni G, Lawton J, Myers PO, Redfors B, Sandner S. European Association of Cardio-Thoracic Surgery (EACTS) expert consensus statement on perioperative myocardial infarction after cardiac surgery. Eur J Cardiothorac Surg 2024; 65:ezad415. [PMID: 38420786 DOI: 10.1093/ejcts/ezad415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/14/2023] [Accepted: 12/12/2023] [Indexed: 03/02/2024] Open
Abstract
Cardiac surgery may lead to myocardial damage and release of cardiac biomarkers through various mechanisms such as cardiac manipulation, systemic inflammation, myocardial hypoxia, cardioplegic arrest and ischaemia caused by coronary or graft occlusion. Defining perioperative myocardial infarction (PMI) after cardiac surgery presents challenges, and the association between the current PMI definitions and postoperative outcomes remains uncertain. To address these challenges, the European Association of Cardio-Thoracic Surgery (EACTS) facilitated collaboration among a multidisciplinary group to evaluate the existing evidence on the mechanisms, diagnosis and prognostic implications of PMI after cardiac surgery. The review found that the postoperative troponin value thresholds associated with an increased risk of mortality are markedly higher than those proposed by all the current definitions of PMI. Additionally, it was found that large postoperative increases in cardiac biomarkers are prognostically relevant even in absence of additional supportive signs of ischaemia. A new algorithm for PMI detection after cardiac surgery was also proposed, and a consensus was reached within the group that establishing a prognostically relevant definition of PMI is critically needed in the cardiovascular field and that PMI should be included in the primary composite outcome of coronary intervention trials.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich, UK
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Davide Capodanno
- Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Giuseppe Biondi Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | - William E Boden
- VA New England Healthcare System, Boston University School of Medicine, Boston, MA, USA
| | - P J Devereaux
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Michael Farkouh
- Academic Affairs, Cedars-Sinai Health System, Los Angeles, CA, USA
| | - Nicholas Freemantle
- Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Stephen Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of Cardiac Surgery, University of Toronto, Toronto, ON, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - John Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY, USA
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Jennifer Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Patrick O Myers
- Department of Cardiac Surgery, CHUV-Center Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Björn Redfors
- Cardiovascular Research Foundation, New York, NY, USA
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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Bana A, Sangal A, Mehta N, Jaiswal S, Tirkey S, Yadav VK, Sharma KK, Gupta R. Off-pump CABG surgery in left main coronary artery disease: a single-center prospective registry. Indian J Thorac Cardiovasc Surg 2023; 39:446-452. [PMID: 37609610 PMCID: PMC10441988 DOI: 10.1007/s12055-023-01526-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 04/16/2023] [Accepted: 04/19/2023] [Indexed: 08/24/2023] Open
Abstract
Background and objective The treatment of left main (LM) coronary artery disease (CAD) requires complex decision-making. Patients with left main multi-vessel coronary artery disease (LM CAD) have concerns regarding incomplete revascularization and reduced survival with off-pump (OPCAB) when compared with on-pump (ONCAB) coronary bypass surgery. To evaluate outcomes among high-risk LM CAD patients undergoing OPCAB, we performed a registry-based prospective study. Methods We performed 4868 coronary artery bypass graft (CABG) surgeries from Jan 2013 to Jun 2019 with 4662 (95.8%) OPCAB. In OPCAB cohort, we had 1323 patients (28.4%) with significant LM (> 50%) triple vessel CAD. Data regarding clinical features, extent of CAD, operative details, in-hospital outcomes, and 3-year follow-up were obtained. Descriptive statistics are reported. Results The study cohort (n = 1323) was aged 63 ± 9 years with men 88.4%. Tobacco use was in 328 (24.8%), diabetes 598 (45.2%), previous myocardial infarction 463 (35.0%), previous coronary intervention 40 (3.0%), and congestive heart failure in 54 (4.1%). All patients had LM (100.0%) with triple vessel disease in 99.4% (LAD, left anterior descending 100.0%; LCX, left circumflex 99.4%; RCA, right coronary artery 78.7%). Vessels bypassed/patient were 2.7 ± 0.4 with 3.2 ± 0.7 total grafts and 2.1 ± 0.8 venous grafts. In total, 1278 (96.5%) patients received left internal mammary artery (LIMA), 63(4.7%) bilateral internal mammary artery (BIMA), and 74 (5.6%) radial artery grafts. There was no patient with conversion from OPCAB to ONCAB. In-hospital major adverse cardiovascular events (MACE: all-cause deaths, myocardial infarction, and stroke) were in 21 (1.6%). At 3-year follow-up (n = 1041), MACE rates were in 84 (8.1%) and cardiovascular deaths in 28 (2.7%). Conclusions This study shows that off-pump CABG surgery is safe in patients with LM CAD. There is low in-hospital mortality and MACE and 3-year outcomes are similar to the published data of LM CAD patients who undergo on-pump CABG. Supplementary Information The online version contains supplementary material available at 10.1007/s12055-023-01526-3.
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Affiliation(s)
- Ajeet Bana
- Eternal Heart Care Centre & Research Institute, Jawahar Nagar, Jaipur, 302017 India
| | - Anuj Sangal
- Department of CTVS, Eternal Heart Care Centre & Research Institute, Jawahar Nagar, Jaipur, 302017 India
- Eternal Heart Care Centre & Research Institute, Room 102, Ground Floor, Jagatpura Road, Jawahar Circle, Jaipur, 301017 India
| | - Navneet Mehta
- Department of Cardiac Anaesthesia, Eternal Heart Care Centre & Research Institute, Jawahar Nagar, Jaipur, 302017 India
| | - Saurabh Jaiswal
- Department of CTVS, Parivar Superspeciality Hospital, Gwalior, 474001 India
| | - Sundeep Tirkey
- Department of CTVS, B.L. Kapoor-Max Hospital, Rajender Nagar, New Delhi, 110005 India
| | - Vimal Kant Yadav
- Department of CTVS, Eternal Heart Care Centre & Research Institute, Jawahar Nagar, Jaipur, 302017 India
| | - Krishna Kumar Sharma
- Department of Pharmacology, Lal Bahadur Shastri College of Pharmacy, Rajasthan University of Health Sciences, Jaipur, 302017 India
| | - Rajeev Gupta
- Department of Preventive Cardiology and Internal Medicine, Eternal Heart Care Centre & Research Institute, Jawahar Nagar, Jaipur, 302017 India
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Applicability of the EXCEL Trial Criteria to an All-Comers Real-World Cohort of Unprotected Left Main Percutaneous Coronary Intervention. Am J Cardiol 2023; 195:98-106. [PMID: 36804737 DOI: 10.1016/j.amjcard.2023.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/26/2022] [Accepted: 01/13/2023] [Indexed: 02/20/2023]
Abstract
The Evaluation of XIENCE versus EXCEL (Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial is the largest randomized study comparing percutaneous coronary intervention (PCI) with second-generation drug-eluting stents and bypass surgery in unprotected left main disease (ULMD). Our aim was to assess which proportion of patients from a contemporary all-comer population of ULMD PCI would be eligible for the EXCEL trial and whether these patients show different long-term outcomes than the rest of the ULMD population. A total of 246 consecutive patients underwent ULMD PCI between January 2018 and December 2021 and were retrospectively analyzed. After application of the EXCEL trial inclusion and exclusion criteria, 98 patients (39%) were allocated to the "EXCEL-like" cohort and 148 to the "non-EXCEL-like." Baseline characteristics of the 2 groups were substantially comparable. The mean baseline SYNTAX score was lower in the EXCEL-like patients than the non-EXCEL-like group (20.1 ± 7.1 vs 23.0 ± 11.2, p = 0.025), with the latter also showing a higher degree of incomplete revascularization (residual SYNTAX score >8 : 11% vs 26%, p = 0.005). At 1 year, the cumulative major adverse cardiovascular and cerebral events rate was 7% for the EXCEL-like and 17% for the non-EXCEL-like patients, respectively (p = 0.03). At the last follow-up available, the significant difference in major adverse cardiovascular and cerebral events rate persisted (19% vs 37%, p = 0.02) and a significant difference in any unplanned revascularization was also shown (1.5% vs 13%, p = 0.04). In conclusion, in a contemporary real-world cohort of ULMD PCI, only a minority of patients could be enrolled in the EXCEL trial; the EXCEL-like patients, in our population, showed less clinical events at long-term follow-up than the cohort of patients who were ineligible for EXCEL, despite comparable baseline cardiovascular profiles; these findings may challenge a broad external applicability of the results of the EXCEL trial in routine clinical activity.
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5
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Jain SS, Li D, Dressler O, Kotinkaduwa L, Serruys PW, Kappetein AP, Sabik JF, Morice MC, Puskas J, Kandzari DE, Karmpaliotis D, Lembo NJ, Brown WM, Banning AP, Stone GW. Impact of Periprocedural Adverse Events After PCI and CABG on 5-Year Mortality: The EXCEL Trial. JACC Cardiovasc Interv 2023; 16:303-313. [PMID: 36792254 DOI: 10.1016/j.jcin.2022.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 10/04/2022] [Accepted: 10/04/2022] [Indexed: 02/16/2023]
Abstract
BACKGROUND The relative risks for different periprocedural major adverse events (MAE) after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) on subsequent mortality have not been described. OBJECTIVES The aim of this study was to assess the association between periprocedural MAE occurring within 30 days postprocedure and early and late mortality after left main coronary artery revascularization by PCI and CABG. METHODS In the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, patients with left main disease were randomized to PCI vs CABG. The associations between 12 prespecified nonfatal MAE and subsequent 5-year all-cause and cardiovascular death in 1,858 patients were examined using logistic regression. RESULTS One or more nonfatal MAE occurred in 111 of 935 patients (11.9%) after PCI and 419 of 923 patients (45.4%) after CABG (P < 0.0001). Patients with MAE were older and had more baseline comorbidities. Within 5 years, all-cause death occurred in 117 and 87 patients after PCI and CABG, respectively. Experiencing an MAE was a strong independent predictor of 5-year mortality after both PCI (adjusted OR: 4.61; 95% CI: 2.71-7.82) and CABG (adjusted OR: 3.25; 95% CI: 1.95-5.41). These associations were present within the first 30 days and between 30 days and 5 years postprocedure. Major or minor bleeding with blood transfusion ≥2 U was an independent predictor of 5-year mortality after both procedures. Stroke, unplanned revascularization for ischemia, and renal failure were significantly associated with mortality only after CABG. CONCLUSIONS In the EXCEL trial, nonfatal periprocedural MAE were strongly associated with early and late mortality after both PCI and CABG for left main disease.
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Affiliation(s)
- Sneha S Jain
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, California, USA
| | - Ditian Li
- Cardiovascular Research Foundation, New York, New York, USA
| | | | | | - Patrick W Serruys
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Joseph F Sabik
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | | | - John Puskas
- Mount Sinai Heart at Mount Sinai Saint Luke's, New York, New York, USA
| | | | - Dimitri Karmpaliotis
- Cardiovascular Research Foundation, New York, New York, USA; NewYork-Presbyterian Hospital and Columbia University Medical Center, New York, New York, USA
| | - Nicholas J Lembo
- Cardiovascular Research Foundation, New York, New York, USA; NewYork-Presbyterian Hospital and Columbia University Medical Center, New York, New York, USA
| | | | - Adrian P Banning
- John Radckiffe, Oxford University Hospitals, Oxford, United Kingdom
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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Magnuson EA, Chinnakondepalli K, Vilain K, Serruys PW, Sabik JF, Kappetein AP, Stone GW, Cohen DJ. Cost-Effectiveness of Percutaneous Coronary Intervention Versus Bypass Surgery for Patients With Left Main Disease: Results From the EXCEL Trial. Circ Cardiovasc Interv 2022; 15:e011981. [PMID: 35861797 DOI: 10.1161/circinterventions.122.011981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) demonstrated in patients with left main coronary artery disease, no significant difference between coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) with everolimus-eluting stents for the composite end point of death, stroke, or myocardial infarction at 5 years. However, all-cause mortality at 5 years was higher with PCI. Long-term cost-effectiveness of these 2 strategies has heretofore not been evaluated. METHODS From 2010 to 2014, 1905 patients with left main coronary artery disease were randomized to CABG (n=957) or PCI (n=948). Costs ($2019) were assessed over 5 years using resource-based costing and Medicare reimbursement rates. Health utilities were assessed using the EuroQOL 5-dimension questionnaire. Five-year EXCEL data in combination with US lifetables were used to develop a Markov model to evaluate lifetime cost-effectiveness. An incremental cost-effectiveness ratio <$50 000 per quality-adjusted life year (QALY) gained was considered highly cost-effective. RESULTS Index revascularization procedure costs were $4,850/patient higher with CABG, and total costs for the index hospitalization were $17 610/patient higher with CABG ($32 297 versus $19 687, P<0.001). Cumulative 5-year costs were $20 449/patient higher with CABG. CABG was projected to increase lifetime costs by $21 551 while increasing quality-adjusted life expectancy by 0.49 QALYs, yielding an incremental cost-effectiveness ratio of $44 235/QALY. In a post hoc sensitivity analysis using mortality hazard ratios from a meta-analysis of all randomized CABG versus PCI in left main disease trials, the gain associated with CABG was 0.08 to 0.14 QALYs, resulting in an incremental cost-effectiveness ratio of $139 775 to $232 710/QALY gained. CONCLUSIONS Based on data from the EXCEL trial, CABG is an economically attractive revascularization strategy compared with PCI over a lifetime horizon for patients with significant left main coronary artery disease. However, this conclusion is sensitive to the long-term mortality rates with the 2 strategies, and CABG is no longer highly cost-effective when substituting the pooled treatment effect from the 4 major PCI versus CABG trials for left main disease. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01205776.
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Affiliation(s)
- Elizabeth A Magnuson
- Saint Luke's Mid America Heart Institute, Kansas City, MO (E.A.M., K.C., K.V.).,University of Missouri-Kansas City (E.A.M.)
| | | | - Katherine Vilain
- Saint Luke's Mid America Heart Institute, Kansas City, MO (E.A.M., K.C., K.V.)
| | - Patrick W Serruys
- National Heart and Lung Institute, Imperial College London, United Kingdom (P.W.S.)
| | - Joseph F Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, OH (J.F.S.)
| | - A Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands (A.P.K.).,Medtronic, Maastricht, the Netherlands (A.P.K.)
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (G.W.S.).,Cardiovascular Research Foundation, New York, NY (G.W.S., D.J.C.)
| | - David J Cohen
- Cardiovascular Research Foundation, New York, NY (G.W.S., D.J.C.).,Saint Francis Hospital and Heart Center, Roslyn, NY (D.J.C.)
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Myat A, Hildick-Smith D, de Belder AJ, Trivedi U, Crowley A, Morice MC, Kandzari DE, Lembo NJ, Brown WM, Serruys PW, Kappetein AP, Sabik JF, Stone G. Geographical variations in left main coronary artery revascularisation: a prespecified analysis of the EXCEL trial. EUROINTERVENTION 2022; 17:1081-1090. [PMID: 34212863 PMCID: PMC9724945 DOI: 10.4244/eij-d-21-00338] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The EXCEL trial reported similar five-year rates of the primary composite outcome of death, myocardial infarction (MI), or stroke after percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG) for treatment of obstructive left main coronary artery disease (LMCAD). AIMS We sought to determine whether these outcomes remained consistent regardless of geography of enrolment. METHODS We performed a prespecified subgroup analysis based on regional enrolment. RESULTS Among 1,905 patients randomised to PCI (n=948) or CABG (n=957), 1,075 (56.4%) were recruited at 52 European Union (EU) centres, and 752 (39.5%) were recruited at 67 North American (NA) centres. EU versus NA patients varied according to numerous baseline demographics, anatomy, pharmacotherapy and procedural characteristics. Nonetheless, the relative rates of the primary endpoint after PCI versus CABG were consistent across EU versus NA centres at 30 days and 5 years. However, NA participants had substantially higher late rates of ischaemia-driven revascularisation (IDR) after PCI, driven predominantly by the need for greater target vessel and lesion revascularisation. This culminated in a significant difference in the relative risk of the secondary composite outcome of death, MI, stroke, or IDR at 5 years (pinteraction=0.02). CONCLUSIONS In the EXCEL trial, the relative risks for the 30-day and five-year primary composite outcome of death, MI or stroke after PCI versus CABG were consistent irrespective of geography. However, five-year rates of IDR after PCI were significantly higher in NA centres, a finding the Heart Team and patients should consider when making treatment decisions. ClinicalTrials.gov identifier: NCT01205776.
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Affiliation(s)
- Aung Myat
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom,Division of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Adam J. de Belder
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Uday Trivedi
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Aaron Crowley
- Clinical Trials Centre, Cardiovascular Research Foundation, New York, NY, USA
| | | | | | - Nicholas J. Lembo
- Clinical Trials Centre, Cardiovascular Research Foundation, New York, NY, USA,NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | | | - Patrick W. Serruys
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland,Department of Cardiology, Imperial College London, London, United Kingdom
| | | | - Joseph F. Sabik
- Department of Surgery, UH Cleveland Medical Center, Cleveland, OH, USA
| | - Gregg Stone
- Mount Sinai Hospital, Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY 10019, USA
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8
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Key Issues in the Statistical Interpretation of Randomized Clinical Trials. Can J Cardiol 2021; 37:1312-1321. [DOI: 10.1016/j.cjca.2020.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/16/2020] [Accepted: 12/18/2020] [Indexed: 01/10/2023] Open
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Magro P, Sousa-Uva M. Left main stenosis: Can a consensus be reached? Rev Port Cardiol 2021; 40:619-622. [PMID: 34392907 DOI: 10.1016/j.repce.2021.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Pedro Magro
- Serviço de Cirurgia Cardíaca, Hospital da Santa Cruz, Carnaxide, Portugal
| | - Miguel Sousa-Uva
- Serviço de Cirurgia Cardíaca, Hospital da Santa Cruz, Carnaxide, Portugal.
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10
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Magro P, Sousa-Uva M. Left main stenosis: Can a consensus be reached? Rev Port Cardiol 2021. [DOI: 10.1016/j.repc.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Beohar N, Chen S, Lembo NJ, Banning AP, Serruys PW, Leon MB, Morice MC, Généreux P, Kandzari DE, Kappetein AP, Sabik JF, Dressler O, McAndrew T, Zhang Z, Stone GW. Impact of lesion preparation strategies on outcomes of left main PCI: The EXCEL trial. Catheter Cardiovasc Interv 2021; 98:24-32. [PMID: 32592450 DOI: 10.1002/ccd.29116] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES We examined outcomes according to lesion preparation strategy (LPS) in patients with left main coronary artery (LMCA) percutaneous coronary intervention (PCI) in the EXCEL trial. BACKGROUND The optimal LPS for LMCA PCI is unclear. METHODS We categorized LPS hierarchically (high to low) as: (a) rotational atherectomy (RA); (b) cutting or scoring balloon (CSB); (c) balloon angioplasty (BAL); and d) direct stenting (DIR). The primary endpoint was 3-year MACE; all-cause death, stroke, or myocardial infarction. RESULTS Among 938 patients undergoing LMCA PCI, RA was performed in 6.0%, CSB 9.5%, BAL 71.3%, and DIR 13.2%. In patients treated with DIR, BAL, CSB, and RA, respectively, there was a progressive increase in SYNTAX score, LMCA complex bifurcation, trifurcation or calcification, number of stents, and total stent length. Any procedural complication occurred in 10.4% of cases overall, with the lowest rate in the DIR (7.4%) and highest in the RA group (16.1%) (ptrend = .22). There were no significant differences in the 3-year rates of MACE (from RA to DIR: 17.9%, 20.2%, 14.5%, 14.7%; p = .50) or ischemia-driven revascularization (from RA to DIR: 16.8%, 10.8%, 12.3%, 14.2%; p = .65). The adjusted 3-year rates of MACE did not differ according to LPS. CONCLUSIONS The comparable 3-year outcomes suggest that appropriate lesion preparation may be able to overcome the increased risks of complex LMCA lesion morphology.
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Affiliation(s)
- Nirat Beohar
- Columbia University Division of Cardiology at the Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Shmuel Chen
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA.,New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Nicholas J Lembo
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA.,New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | | | - Patrick W Serruys
- Department of Cardiology, NUIG, National University of Ireland, Galway, Ireland.,Imperial College of Science Technology and Medicine, London, UK
| | - Martin B Leon
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA.,New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Marie-Claude Morice
- Ramsay Générale de Santé, Institut Cardiovasculaire Paris Sud, Paris, France
| | - Philippe Généreux
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA.,Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA.,Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | | | | | - Joseph F Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Ovidiu Dressler
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Thomas McAndrew
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Zixuan Zhang
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Gregg W Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA.,The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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12
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Impact of renin-angiotensin system inhibitors after revascularization of patients with left main coronary artery disease. Coron Artery Dis 2021; 31:37-44. [PMID: 34010183 DOI: 10.1097/mca.0000000000001053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is a paucity of data regarding the effect of inhibition of the renin-angiotensin system on outcomes after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). We sought to examine long-term outcomes of patients with left main coronary disease (LMCAD) randomized to PCI with fluoropolymer-based cobalt-chromium everolimus-eluting stents or CABG according to treatment at discharge with angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) in the large-scale, multicenter, randomized EXCEL trial. METHODS EXCEL randomized 1905 patients with LMCAD of low and intermediate anatomical complexity (visually-assessed SYNTAX score ≤32) to PCI (n = 948) versus CABG (n = 957). Patients were categorized according to whether they were treated with ACEI/ARB at discharge; their outcomes from discharge to 5 years were examined using multivariable logistic regression with an offset for follow-up time. RESULTS Among 1775 patients discharged alive with known ACEI/ARB treatment status, 896 (50.5%) were treated with one of these agents. Among those treated with ACEI/ARB, the 5-year rate of all-cause death was similar after PCI or CABG (10.7% versus 9.8% respectively, adjOR, 0.94; 95% CI, 0.56-1.57) in contrast to patients not treated with ACEI/ARB (15.0% versus 7.8%, respectively, adjOR, 2.20; 95% CI, 1.32-3.67) (Pinteraction = 0.02). Significant interactions between treatment arm (PCI versus CABG) and ACEI/ARB treatment status were also found for cardiovascular death (Pinteraction = 0.03), ischemia-driven revascularization (Pinteraction = 0.03), target vessel revascularization (Pinteraction = 0.007) and target vessel failure (Pinteraction = 0.0009). CONCLUSION In the EXCEL trial, the postdischarge rates of death and revascularization after 5 years were similar after PCI and CABG in patients with LMCAD treated with ACEI/ARB at discharge. In contrast, event rates were higher after PCI versus CABG in those not so treated.
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13
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White blood cell count and clinical outcomes after left main coronary artery revascularization: insights from the EXCEL trial. Coron Artery Dis 2021; 31:45-51. [PMID: 34010180 DOI: 10.1097/mca.0000000000001052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prior studies have reported an association between elevated white blood cell count (WBCc) and worse clinical outcomes after coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). We assessed the prognostic impact of WBCc in patients undergoing revascularization for left main coronary artery disease (LMCAD). METHODS In Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL), 1905 patients with LMCAD and low or intermediate SYNTAX scores were randomized to PCI with everolimus-eluting stents versus CABG. The 1895 patients with baseline WBCc available were grouped in tertiles of WBCc (mean 5.6 ± 0.8, 7.5 ± 0.5, and 10.1 ± 1.6 × 109/L). RESULTS Five-year rates of the primary endpoint (death, myocardial infarction or stroke) were similar across increasing WBCc tertiles (21.2, 18.9, and 21.6%; P = 0.46). Individual components of the primary endpoint, Bleeding Academic Research Consortium (BARC) 3-5 bleeding, stent thrombosis or graft occlusion and ischemia-driven revascularization were all similar across WBCc tertiles. By multivariable analysis, WBCc as a continuous variable was not an independent predictor of adverse events (hazard radio per 1 × 109/L: 1.02; 95% CI, 0.97-1.08; P = 0.43). Results were consistent in the PCI and CABG arms individually. CONCLUSION There was no association between baseline WBCc and 30-day or 5-year clinical outcomes after PCI or CABG. The absence of a clear incremental increase in events with increasing WBCc in the current analysis indicates that WBCc should not routinely be used as a prognostic marker or to guide revascularization decisions in patients with LMCAD.
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14
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Gaba P, Serruys PW, Karmpaliotis D, Lembo NJ, Banning AP, Zhang Z, Morice MC, Kandzari DE, Gershlick AH, Ben-Yehuda O, Sabik JF, Kappetein AP, Stone GW. Outpatient Versus Inpatient Percutaneous Coronary Intervention in Patients With Left Main Disease (from the EXCEL Trial). Am J Cardiol 2021; 143:21-28. [PMID: 33359193 DOI: 10.1016/j.amjcard.2020.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 11/30/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
Prior studies in patients with noncomplex coronary artery disease have demonstrated the safety of percutaneous coronary intervention (PCI) in the outpatient setting. We sought to examine the outcomes of outpatient PCI in patients with unprotected left main coronary artery disease (LMCAD). In the EXCEL trial, 1905 patients with LMCAD and site-assessed low or intermediate SYNTAX scores were randomized to PCI with everolimus-eluting stents versus coronary artery bypass grafting. The primary end point was major adverse cardiovascular events (MACE; the composite of death, stroke, or myocardial infarction). In this sub-analysis, outcomes at 30 days and 5 years were analyzed according to whether PCI was performed in the outpatient versus inpatient setting. Among 948 patients with LMCAD assigned to PCI, 935 patients underwent PCI as their first procedure, including 100 (10.7%) performed in the outpatient setting. Patients who underwent outpatient compared with inpatient PCI were less likely to have experienced recent myocardial infarction. Distal left main bifurcation disease involvement and SYNTAX scores were similar between the groups. Comparing outpatient to inpatient PCI, there were no significant differences in MACE at 30 days (4.0% vs 5.0% respectively, adjusted OR 0.52 95% CI 0.12 to 2.22; p = 0.38) or 5 years (20.6% vs 22.1% respectively, adjusted OR 0.72, 95% CI 0.40 to 1.29; p = 0.27). Similar results were observed in patients with distal left main bifurcation lesions. In conclusion, in the EXCEL trial, outpatient PCI of patients with LMCAD was not associated with an excess early or late hazard of MACE. These data suggest that outpatient PCI may be safely performed in select patients with LMCAD.
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15
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Redfors B, Mohebi R, Giustino G, Chen S, Selker HP, Thiele H, Patel MR, Udelson JE, Ohman EM, Eitel I, Granger CB, Maehara A, Ali ZA, Ben-Yehuda O, Stone GW. Time Delay, Infarct Size, and Microvascular Obstruction After Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction. Circ Cardiovasc Interv 2021; 14:e009879. [PMID: 33440999 DOI: 10.1161/circinterventions.120.009879] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Symptom-to-balloon time (SBT) and door-to-balloon time (DBT) are both considered important metrics in patients undergoing primary percutaneous coronary intervention (pPCI) for ST-segment-elevation myocardial infarction (STEMI). We sought to assess the relationship of SBT and DBT with infarct size and microvascular obstruction (MVO) after pPCI. METHODS Individual patient data for 3115 ST-segment-elevation myocardial infarction patients undergoing pPCI in 10 randomized trials were pooled. Infarct size (% left ventricular mass) was assessed within 1 month after randomization by technetium-99 m sestamibi single-photon emission computerized tomography (3 studies) or cardiac magnetic resonance imaging (7 studies). MVO was assessed by cardiac magnetic resonance. Patients were stratified by short (≤2 hours), intermediate (2-4 hours), or long (>4 hours) SBTs, and by short (≤45 minutes), intermediate (45-90 minutes), or long (>90 minutes) DBTs. RESULTS Median [interquartile range] SBT and DBT were 185 [130-269] and 46 [28-83] minutes, respectively. Median [interquartile range] time to infarct size assessment after pPCI was 5 [3-12] days. There was a stepwise increase in infarct size according to SBT category (adjusted difference, 2.0% [95% CI, 0.4-3.5] for intermediate versus short SBT and 4.4% [95% CI, 2.7-6.1] for long versus short SBT) but not according to DBT category (adjusted difference, 0.4% [95% CI, -1.2 to 1.9] for intermediate versus short DBT and -0.1% [95% CI, -1.0 to 3.0] for long versus short SBT). MVO was greater in patients with long versus short SBT (adjusted difference, 0.9% [95% CI, 0.3-1.4]) but was not different between patients with intermediate versus short SBT (adjusted difference, 0.1 [95% CI, -0.4 to 0.6]). There was no difference in MVO according to DBT. Results were similar in multivariable analysis with SBT and DBT included as continuous variables. CONCLUSIONS Among 3115 patients with ST-segment-elevation myocardial infarction undergoing infarct size assessment after pPCI, SBT was more strongly correlated with infarct size and MVO than DBT.
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Affiliation(s)
- Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., R.M., S.C., A.M., Z.A.A., O.B.-Y., G.W.S.).,Department of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY (B.R., S.C., A.M., Z.A.A., O.B.-Y.).,Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (B.R.)
| | - Reza Mohebi
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., R.M., S.C., A.M., Z.A.A., O.B.-Y., G.W.S.).,The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.G., G.W.S.)
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.G., G.W.S.)
| | - Shmuel Chen
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., R.M., S.C., A.M., Z.A.A., O.B.-Y., G.W.S.).,Department of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY (B.R., S.C., A.M., Z.A.A., O.B.-Y.)
| | - Harry P Selker
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (H.P.S.)
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Germany (H.T.)
| | - Manesh R Patel
- Duke University Medical Center, Durham, NC (M.R.P., E.M.O., C.B.G.)
| | - James E Udelson
- Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U.)
| | - E Magnus Ohman
- Duke University Medical Center, Durham, NC (M.R.P., E.M.O., C.B.G.)
| | - Ingo Eitel
- University Heart Center Lübeck, and the German Center for Cardiovascular Research, Lübeck, Germany (I.E.)
| | | | - Akiko Maehara
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., R.M., S.C., A.M., Z.A.A., O.B.-Y., G.W.S.).,Department of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY (B.R., S.C., A.M., Z.A.A., O.B.-Y.)
| | - Ziad A Ali
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., R.M., S.C., A.M., Z.A.A., O.B.-Y., G.W.S.).,Department of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY (B.R., S.C., A.M., Z.A.A., O.B.-Y.).,St. Francis Hospital, Roslyn, NY (Z.A.A.)
| | - Ori Ben-Yehuda
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., R.M., S.C., A.M., Z.A.A., O.B.-Y., G.W.S.).,Department of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY (B.R., S.C., A.M., Z.A.A., O.B.-Y.)
| | - Gregg W Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., R.M., S.C., A.M., Z.A.A., O.B.-Y., G.W.S.).,The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.G., G.W.S.)
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16
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Kawashima H, Pompilio G, Andreini D, Bartorelli AL, Mushtaq S, Ferrari E, Maisano F, Buechel RR, Tanaka K, La Meir M, De Mey J, Schneider U, Doenst T, Teichgräber U, Stone GW, Sharif F, de Winter R, Thomsen B, Taylor C, Rogers C, Leipsic J, Wijns W, Onuma Y, Serruys PW. Safety and feasibility evaluation of planning and execution of surgical revascularisation solely based on coronary CTA and FFR CT in patients with complex coronary artery disease: study protocol of the FASTTRACK CABG study. BMJ Open 2020; 10:e038152. [PMID: 33303435 PMCID: PMC7733219 DOI: 10.1136/bmjopen-2020-038152] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 07/18/2020] [Accepted: 10/30/2020] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION The previously published SYNTAX III REVOLUTION trial demonstrated that clinical decision-making between coronary artery bypass graft (CABG) and percutaneous coronary intervention based on coronary CT angiography (CCTA) had a very high agreement with the treatment decision derived from invasive coronary angiography (ICA). The study objective of the FASTTRACK CABG is to assess the feasibility of CCTA and fractional flow reserve derived from CTA (FFRCT) to replace ICA as a surgical guidance method for planning and execution of CABG in patients with three-vessel disease with or without left main disease. METHODS AND ANALYSIS The FASTTRACK CABG is an investigator-initiated single-arm, multicentre, prospective, proof-of-concept and first-in-man study with feasibility and safety analysis. Surgical revascularisation strategy and treatment planning will be solely based on CCTA and FFRCT without knowledge of the anatomy defined by ICA. Clinical follow-up visit including CCTA will be performed 30 days after CABG in order to assess graft patency and adequacy of the revascularisation with respect to the surgical planning based on non-invasive imaging (CCTA) with functional assessment (FFRCT) and compared with ICA. Primary feasibility endpoint is CABG planning and execution solely based on CCTA and FFRCT in 114 patients. Primary safety endpoint based on 30 day CCTA is graft assessment and topographical adequacy of the revascularisation procedure. Automatic non-invasive assessment of functional coronary anatomy complexity is also evaluated with FFRCT for functional Synergy Between percutaneous coronary intervention With Taxus and Cardiac Surgery Score assessment on CCTA. CCTA with FFRCT might provide better anatomical and functional analysis of the coronary circulation leading to appropriate anatomical and functional revascularisation, and thereby contributing to a better outcome. ETHICS AND DISSEMINATION Each patient has to provide written informed consent as approved by the ethical committee of the respective clinical site. Results will be submitted for publication in peer-reviewed journals and will be disseminated at scientific conferences. TRIAL REGISTRATION NUMBER NCT04142021.
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Affiliation(s)
- Hideyuki Kawashima
- National University of Ireland Galway, Galway, Ireland
- Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Giulio Pompilio
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Daniele Andreini
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Antonio L Bartorelli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| | | | - Enrico Ferrari
- University Hospital and University of Zurich, Zurich, Switzerland
| | | | - Ronny R Buechel
- University Hospital and University of Zurich, Zurich, Switzerland
| | - Kaoru Tanaka
- Universitair Ziekenhuis Brussel, VUB, Brussels, Belgium
| | - Mark La Meir
- Universitair Ziekenhuis Brussel, VUB, Brussels, Belgium
| | - Johan De Mey
- Universitair Ziekenhuis Brussel, VUB, Brussels, Belgium
| | - Ulrich Schneider
- Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Torsten Doenst
- Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Ulf Teichgräber
- Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Gregg W Stone
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
- Cardiovascular Research Foundation, New York City, NY, USA
| | - Faisal Sharif
- National University of Ireland Galway, Galway, Ireland
| | | | | | | | | | - Jonathon Leipsic
- St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - William Wijns
- National University of Ireland Galway, Galway, Ireland
| | | | - Patrick W Serruys
- National University of Ireland Galway, Galway, Ireland
- NHLI, Imperial College London, London, UK
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17
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Malaiapan Y, Leung M, White AJ. The role of intravascular ultrasound in percutaneous coronary intervention of complex coronary lesions. Cardiovasc Diagn Ther 2020; 10:1371-1388. [PMID: 33224763 DOI: 10.21037/cdt-20-189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intravascular ultrasound (IVUS) is a catheter-based coronary imaging technique. It utilises the emission & subsequent detection of reflected high frequency (30-60 MHz) sound waves to create high resolution, cross-sectional images of the coronary artery. IVUS has been the cornerstone of intracoronary imaging for more than two decades. When compared to the invasive coronary angiogram which studies only the silhouette of the contrast-filled artery lumen, IVUS also crucially images the vessel wall. Because of this capability, IVUS has greatly facilitated understanding of the coronary atherosclerosis process. Such insights from IVUS reveal how commonly and extensively plain angiography underestimates the true extent of coronary plaque, the characteristics of plaques prone to rupture and cause acute coronary syndromes (lipid rich, thin cap atheroma), and a realisation of the widespread occurrence of vessel remodelling in response to atherosclerosis. Similarly, IVUS has historically provided salutary mechanistic insights that have guided many of the incremental advances in the techniques of percutaneous coronary intervention (PCI). Examples include mechanisms of in-stent restenosis, and the importance of high-pressure post-dilatation of stents to ensure adequate stent apposition and thereby reduce the occurrence of stent thrombosis. IVUS also greatly facilitates the choice of correct diameter and length of stent to implant. Overall, a compelling body of evidence indicates that use of intravascular ultrasound in PCI helps to achieve optimal technical results and to mitigate the risk of adverse cardiac events. In this review, the role of intravascular ultrasound as an adjunct to PCI in complex coronary lesions is explored. The complex coronary situations discussed are the left main stem, ostial stenoses, bifurcation stenoses, thrombotic lesions, the chronically occluded coronary artery, and calcified coronary artery disease. By thorough review of the available evidence, we establish that the advantages of IVUS guidance are particularly evident in each of these complex CAD subsets. In particular, some consider the use of IVUS to be almost mandatory in left main PCI. A comparison with other intracoronary imaging techniques is also explored.
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Affiliation(s)
- Yuvaraj Malaiapan
- Monash Heart, Monash Medical Centre, Clayton, VIC, Australia.,Department of Medicine, Monash University, Clayton, VIC, Australia
| | - Michael Leung
- Monash Heart, Monash Medical Centre, Clayton, VIC, Australia.,Department of Medicine, Monash University, Clayton, VIC, Australia
| | - Anthony J White
- Monash Heart, Monash Medical Centre, Clayton, VIC, Australia.,Department of Medicine, Monash University, Clayton, VIC, Australia
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18
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Asano T, Kogame N, Onuma Y, Modolo R, Chichareon P, Lefèvre T, Legutko J, Digne F, Morel MA, Serruys PW, Gil RJ. Treatment with a dedicated bifurcation sirolimus-eluting cobalt-chromium stent for distal left main coronary artery disease: rationale and design of the POLBOS LM study. EUROINTERVENTION 2020; 16:654-662. [PMID: 31543500 DOI: 10.4244/eij-d-19-00361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this study is to demonstrate the non-inferiority of the BiOSS LIM C sirolimus-eluting cobalt-chromium bifurcation dedicated stent against the XIENCE stent regarding the patient-oriented composite endpoint (POCE) at 12 months among patients with left main coronary artery disease (LMCA). METHODS AND RESULTS The POLBOS LM study is a single-arm, prospective, multicentre study enrolling 260 patients (SYNTAX score ≤32) with a pre-specified performance goal based on the results of the EXCEL trial with contemporary percutaneous coronary intervention (PCI) for LMCA disease. Patient enrolment will comply with objective inclusion criteria of diameter stenosis ≥50% in the LMCA based on off-line quantitative coronary angiography (QCA) analysed by an independent core laboratory using dedicated bifurcation QCA software. The BiOSS LIM C is used for the treatment of LMCA disease with the same specific technical classification as for the BiOSS LIM (modified MADS classification) and the stent implantation is optimised by using pre-specified intravascular ultrasound criteria. The primary endpoint is POCE (a composite of all-cause death, stroke, any myocardial infarction, and any revascularisation) at 12 months. CONCLUSIONS The POLBOS LM study will indicate the efficacy of the BiOSS LIM C stent with contemporary PCI for distal left main bifurcation lesions in comparison with the XIENCE stent from the recent EXCEL trial, as a performance index.
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Affiliation(s)
- Taku Asano
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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19
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Thuijs DJFM, Head SJ, Stone GW, Puskas JD, Taggart DP, Serruys PW, Dressler O, Crowley A, Brown WM, Horkay F, Boonstra PW, Bogáts G, Noiseux N, Sabik JF, Kappetein AP. Outcomes following surgical revascularization with single versus bilateral internal thoracic arterial grafts in patients with left main coronary artery disease undergoing coronary artery bypass grafting: insights from the EXCEL trial†. Eur J Cardiothorac Surg 2020; 55:501-510. [PMID: 30165487 DOI: 10.1093/ejcts/ezy291] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 07/05/2018] [Accepted: 07/22/2018] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Observational data suggest that the use of a single internal thoracic artery (SITA) may result in inferior outcomes compared with bilateral internal thoracic artery (BITA) use for coronary artery bypass grafting (CABG)-a finding not yet supported by randomized trial outcomes. However, the optimal number of internal thoracic artery grafts in patients with left main coronary artery disease has not been investigated. METHODS The EXCEL trial randomized 1905 patients with left main coronary artery disease to percutaneous coronary intervention with everolimus-eluting stents versus CABG. Among the 905 patients undergoing CABG, 688 (76.0%) received SITA and 217 (24.0%) received BITA. Differences in clinical event rates were estimated using the Kaplan-Meier method and compared with the log-rank test. Multivariable Cox regression was used to adjust for differences in baseline covariates. RESULTS Compared to SITA, patients treated with BITA were younger (66.1 ± 9.5 vs 64.5 ± 9.3 years, P = 0.020), were less likely female (24.3% vs 14.3%, P = 0.002) and diabetic (28.8% vs 15.2%, P < 0.001), and had a lower prevalence of peripheral vessel disease (10.2% vs 5.5%, P = 0.040). The unadjusted 3-year composite primary endpoint of death, stroke or myocardial infarction (MI) occurred in 15.6% of SITA vs 11.6% of BITA patients (P = 0.17). The SITA group tended to have a higher 3-year rate of all-cause death compared with the BITA group (6.7% vs 3.3%; P = 0.070). Stroke, MI and ischaemia-driven revascularization outcomes were not significantly different between groups. After adjusting for baseline differences, neither the composite of death, stroke or MI [hazard ratio (HR) 1.12, 95% confidence interval (CI) 0.71-1.78; P = 0.62] nor mortality (HR 1.36, 95% CI 0.60-3.12; P = 0.46) was significantly higher with SITA. The rehospitalization rate after 3 years was higher in the SITA group (35.8% vs 26.0%, P = 0.008), a difference which was no longer present after multivariable adjustment (HR 1.27, 95% CI 0.93-1.74; P = 0.13). Sternal wound dehiscence within 30 days did not occur more often in the BITA group compared to the SITA group (1.8% vs 2.2%, P > 0.99). CONCLUSIONS In the EXCEL trial, there were no clinical differences at 3 years between SITA or BITA revascularization in patients with left main coronary artery disease.
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Affiliation(s)
- Daniel J F M Thuijs
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - Gregg W Stone
- Department of Cardiology, Columbia University Medical Center, New York-Presbyterian Hospital, Cardiovascular Research Foundation, New York, NY, USA
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Saint Luke's, New York, NY, USA
| | - David P Taggart
- Department of Cardiovascular Surgery, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | | | | | - Aaron Crowley
- Cardiovascular Research Foundation, New York, NY, USA
| | - W Morris Brown
- Department of Cardiovascular Surgery, Piedmont Heart Institute, Atlanta, GA, USA
| | - Ferenc Horkay
- Department of Cardiology, National Institute of Cardiology, Budapest, Hungary
| | - Piet W Boonstra
- Department of Cardiothoracic Surgery, Medical Center Leeuwarden, Leeuwarden, Netherlands
| | - Gabor Bogáts
- Department of Cardiac Surgery, University of Szeged, Szeged, Hungary
| | - Nicolas Noiseux
- Department of Surgery, Faculté de Médecine, Université de Montréal, Montreal, QC, Canada
| | - Joseph F Sabik
- Department of Cardiovascular Surgery, University Hospitals, Cleveland, OH, USA
| | - A Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
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Kurlansky P, Gaudino M. Multiple Arterial Grafting: A Critical Analysis. Am J Cardiol 2020; 132:178-179. [PMID: 32758361 DOI: 10.1016/j.amjcard.2020.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/07/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Paul Kurlansky
- Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, New York
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E 68th St, New York, New York 10065.
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21
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Azzalini L, Stone GW. Percutaneous Coronary Intervention or Surgery for Unprotected Left Main Disease: EXCEL Trial at 5 Years. Interv Cardiol Clin 2020; 9:419-432. [PMID: 32921366 DOI: 10.1016/j.iccl.2020.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Although coronary artery bypass graft (CABG) surgery traditionally has been considered the gold standard for left main revascularization, percutaneous coronary intervention has evolved in the past decades so that it now represents a valid alternative to CABG in a large proportion of cases. The landmark Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial is the largest contemporary randomized comparison assessing the impact of revascularization strategies for left main disease. This review discusses the background, rationale, design, results, and implications of the EXCEL trial.
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Affiliation(s)
- Lorenzo Azzalini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA. https://twitter.com/SportsDoc2009
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA; The Cardiovascular Research Foundation, New York, NY, USA.
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22
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De Maria GL, Scarsini R, Banning AP. Management of Calcific Coronary Artery Lesions: Is it Time to Change Our Interventional Therapeutic Approach? JACC Cardiovasc Interv 2020; 12:1465-1478. [PMID: 31395217 DOI: 10.1016/j.jcin.2019.03.038] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/07/2019] [Accepted: 03/12/2019] [Indexed: 01/07/2023]
Abstract
Patients with obstructive coronary lesions with a high calcium content (LHCC) have an exaggerated clinical risk, because the presence of calcification is associated with more extensive coronary atheroma and higher burden of comorbidities. Treatment of LHCC using percutaneous techniques is complex because of an increased risk of incomplete lesion preparation with suboptimal stent deployment and higher rates of acute and chronic stent failure. Rotational atherectomy has been the predominant technology for treatment of high-grade LHCC, but novel devices/technologies have entered clinical practice. It seems likely that combining enhanced intravascular imaging, which allows definition of the patterns of calcification with these new technologies, will herald a change in procedural algorithms for treatment of LHCC. This review provides an overview about LHCC with special focus on existing and emergent technologies. We also provide a proposed procedural algorithm to facilitate optimal use of technology according to specific features of LHCC and coronary anatomy.
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Affiliation(s)
| | - Roberto Scarsini
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, United Kingdom
| | - Adrian P Banning
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, United Kingdom.
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23
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Kini AS, Dangas GD, Baber U, Vengrenyuk Y, Kandzari DE, Leon MB, Morice MC, Serruys PW, Kappetein AP, Sabik JF, Dressler O, Mehran R, Sharma SK, Stone GW. Influence of final kissing balloon inflation on long-term outcomes after PCI of distal left main bifurcation lesions in the EXCEL trial. EUROINTERVENTION 2020; 16:218-224. [DOI: 10.4244/eij-d-19-00851] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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24
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Biomarkers for infarct diagnosis and rapid rule-out/rule-in of acute myocardial infarction. Herz 2020; 45:509-519. [DOI: 10.1007/s00059-020-04943-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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25
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Thuijs DJFM, Habib RH, Head SJ, Puskas JD, Taggart DP, Stone GW, Zhang Z, Serruys PW, Sabik JF, Kappetein AP. Prognostic performance of the Society of Thoracic Surgeons risk score in patients with left main coronary artery disease undergoing revascularisation: a post hoc analysis of the EXCEL trial. EUROINTERVENTION 2020; 16:36-43. [PMID: 31422924 DOI: 10.4244/eij-d-19-00417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Accurate risk prediction in patients undergoing revascularisation is essential. We aimed to assess the predictive performance of Society of Thoracic Surgeons (STS) risk models in patients with left main coronary artery disease (LMCAD) undergoing coronary artery bypass grafting (CABG) or percutaneous coronary intervention with everolimus-eluting stents (PCI-EES). METHODS AND RESULTS The predictive performance of STS risk models for perioperative mortality, stroke and renal failure was evaluated for their discriminative ability (C statistic) and calibration (Hosmer-Lemeshow goodness-of-fit-test; χ2 and p-values) among patients with LMCAD undergoing PCI-EES (n=935) and CABG (n=923) from the randomised EXCEL trial. STS risk scores, in CABG patients, showed good discrimination for 30-day mortality and average discrimination for stroke (C statistic 0.730 and 0.629, respectively) with average calibration. For PCI, STS risk scores had no discrimination for mortality (C statistic 0.507), yet good discrimination (C statistic 0.751) and calibration for stroke. The predictive performance for renal failure was good for CABG (C statistic 0.82), yet poor for PCI (C statistic 0.59). CONCLUSIONS In selected patients with LMCAD from the EXCEL trial, STS risk models showed good predictive performance for CABG yet lacked predictive performance for PCI for perioperative mortality and renal failure. The STS stroke risk model was surprisingly more discriminating in PCI compared to CABG. Improved and procedure-specific risk prediction instruments are needed to accurately estimate adverse events after LMCAD revascularisation by CABG and PCI. ClinicalTrials.gov Identifier: NCT01205776.
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Affiliation(s)
- Daniel J F M Thuijs
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
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Gomes WJ, Albuquerque LC, Jatene FB, Leal JCF, Rocha EAV, Almeida RMS. The transfiguration of the EXCEL trial: exceeding ethical and moral boundaries. Eur J Cardiothorac Surg 2020; 58:30-34. [DOI: 10.1093/ejcts/ezaa121] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Walter J Gomes
- Cardiovascular Surgery Discipline, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Luciano C Albuquerque
- Sao Lucas Hospital of the Pontifical Catholic University of Porto Alegre, Porto Alegre, RS, Brazil
| | - Fabio B Jatene
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Joao Carlos F Leal
- Faculty of Medicine of São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brazil
| | - Eduardo A V Rocha
- Faculty of Medical Sciences of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Rui M S Almeida
- Faculty of Medicine of the University Center Assis Gurgacz, Cascavel, PR, Brazil
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27
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Commentary: The left main controversy: Is this a real subgroup requiring custom clinical recommendations? J Thorac Cardiovasc Surg 2020; 163:108-110. [DOI: 10.1016/j.jtcvs.2020.04.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 11/20/2022]
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28
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Narayan P. Off-pump versus on-pump bypass surgery for left main coronary artery disease (EXCEL study) - is experience the unknown variable? Indian J Thorac Cardiovasc Surg 2020; 36:253-255. [PMID: 33061136 PMCID: PMC7525569 DOI: 10.1007/s12055-019-00914-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 12/05/2019] [Indexed: 10/25/2022] Open
Abstract
A post hoc analysis of the Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) data compared off-pump coronary artery bypass (OPCAB) technique with conventional coronary artery bypass grafting (CABG). It was reported that OPCAB was associated with lower rate of revascularization especially in the inferolateral wall and carried increased risk of 3-year all-cause mortality compared to on-pump CABG. However, the study does not provide any information on the experience of participating surgeons which is a key determinant of outcomes in OPCAB surgery. In the absence of this key variable, the extrapolation and applicability of this finding to the wider surgical practice, especially in countries like India and Japan, may not be accurate.
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Affiliation(s)
- Pradeep Narayan
- Department of Cardiac Surgery, NH Rabindranath Tagore International Institute of Cardiac Sciences, 124, EM Bypass, Mukundapur, Kolkata, 700099 India
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29
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Milojevic M, Nikolic A, Jüni P, Head SJ. A statistical primer on subgroup analyses. Interact Cardiovasc Thorac Surg 2020; 30:839-845. [DOI: 10.1093/icvts/ivaa042] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/23/2020] [Accepted: 01/29/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
Resources for clinical research are limited. With increasing demand for patient-centred care, which is growing into an integral component of modern medicine, studying outcomes of patients with specific clinical characteristics is becoming increasingly important. Given the high cost of clinical trials and the time it takes to complete an investigation, it has become compulsory for investigators to assess not only treatment effects between the main randomized groups but also to try to identify clinically relevant subgroups that may particularly benefit from specific treatments. Publications of subgroup analyses turned out to be prevalent, and more importantly, these findings play a significant role in strategic planning and decision-making processes. Therefore, raising awareness among clinicians about the concepts and values of subgroup analysis is an aspect of improving patient outcomes. In this statistical primer, we give a broad introduction to the topic of subgroup analysis in scientific research. We furthermore discuss the concept of subgroup analysis; the motivation for assessing subgroups; the types of subgroup analyses and the paradigm of hypothesis-generating research; the proper statistical methods for the examination of subgroup effects; and the optimal approach for interpretation of results. Finally, this review establishes the comprehensive users’ guide for analysing and reporting subgroup studies on a point-by-point basis, using real-world examples that may help readers to gain experience to pursue their own subgroup analyses or interpret those of others.
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Affiliation(s)
- Milan Milojevic
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Aleksandar Nikolic
- Department of Cardiac Surgery, Acibadem Sistina Hospital, Skopje, North Macedonia
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
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Kosmidou I, Liu Y, Zhang Z, Redfors B, Kappetein AP, Serruys PW, Gersh BJ, Kandzari DE, Morice MC, Buszman PE, Bochenek A, Schampaert E, Sabik JF, Ben-Yehuda O, Stone GW. Incidence and Prognostic Impact of Atrial Fibrillation After Discharge Following Revascularization for Significant Left Main Coronary Artery Narrowing. Am J Cardiol 2020; 125:500-506. [PMID: 31813531 DOI: 10.1016/j.amjcard.2019.11.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 11/04/2019] [Accepted: 11/05/2019] [Indexed: 10/25/2022]
Abstract
The incidence, recurrence rate, and prognostic significance of atrial fibrillation or flutter (AF) following hospital discharge after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for left main coronary artery disease (LMCAD) are unknown. We sought to determine the 3-year incidence and clinical impact of postdischarge AF in patients with LMCAD treated with PCI or CABG. In the EXCEL trial, 1,905 patients with LMCAD were randomized to PCI versus CABG. We analyzed the occurrence of postdischarge AF through 3 years and its time-adjusted association with adverse outcomes. A total of 1,802 patients without AF at baseline comprised the study cohort. Within 3 years, 227 episodes of AF occurred (29 [12.8%] in the PCI arm and 198 [87.2%] in the CABG arm, p <0.0001); of those, 63 (27.7%) occurred following discharge from the index hospitalization in 57 patients. In-hospital AF predicted postdischarge AF (hazard ratio [HR] 2.94, 95% confidence interval [CI] 1.42 to 6.10, p = 0.004). By multivariable analysis, time-updated postdischarge AF was an independent predictor of 3-year cardiovascular death (HR 4.91, 95% CI 1.92 to 12.60, p = 0.0009), stroke (HR 4.87, 95% CI 1.12 to 21.12, p = 0.035), and the composite outcome of death, stroke or myocardial infarction (HR 3.09, 95% CI 1.56 to 3.6-6.11, p = 0.001). Among patients with postdischarge AF, the rate of the primary composite outcome did not vary according to presence or absence of in-hospital AF (21.0% vs 23.8%, p = 0.78). In conclusion, postdischarge AF following CABG or PCI for LMCAD is associated with increased mortality and stroke. In-hospital atrial fibrillation is an independent predictor of AF following discharge.
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31
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Thuijs DJ, Milojevic M, Stone GW, Puskas JD, Serruys PW, Sabik JF, Dressler O, Crowley A, Head SJ, Kappetein AP. Impact of left ventricular ejection fraction on clinical outcomes after left main coronary artery revascularization: results from the randomized EXCEL trial. Eur J Heart Fail 2020; 22:871-879. [DOI: 10.1002/ejhf.1681] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/20/2019] [Accepted: 10/24/2019] [Indexed: 12/28/2022] Open
Affiliation(s)
- Daniel J.F.M. Thuijs
- Department of Cardiothoracic Surgery, Erasmus MC University Medical Centre Rotterdam The Netherlands
| | - Milan Milojevic
- Department of Cardiothoracic Surgery, Erasmus MC University Medical Centre Rotterdam The Netherlands
| | - Gregg W. Stone
- Division of Cardiology New York‐Presbyterian Hospital/Columbia University Medical Center New York NY USA
- Clinical Trials Center Cardiovascular Research Foundation New York NY USA
| | - John D. Puskas
- Department of Cardiovascular Surgery Mount Sinai Heart at Mount Saint Luke's New York NY USA
| | | | - Joseph F. Sabik
- Department of Surgery UH Cleveland Medical Center Cleveland OH USA
| | - Ovidiu Dressler
- Clinical Trials Center Cardiovascular Research Foundation New York NY USA
| | - Aaron Crowley
- Clinical Trials Center Cardiovascular Research Foundation New York NY USA
| | - Stuart J. Head
- Department of Cardiothoracic Surgery, Erasmus MC University Medical Centre Rotterdam The Netherlands
| | - A. Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus MC University Medical Centre Rotterdam The Netherlands
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Usefulness of Discharge Resting Heart Rate to Predict Adverse Cardiovascular Outcomes in Patients With Left Main Coronary Artery Disease Revascularized With Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting (from the EXCEL Trial). Am J Cardiol 2020; 125:169-175. [PMID: 31735328 DOI: 10.1016/j.amjcard.2019.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/07/2019] [Accepted: 10/10/2019] [Indexed: 11/23/2022]
Abstract
The prognostic impact of resting heart rate (RHR) following revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with left main coronary artery disease (LMCAD) is unknown. We aimed to assess the effect of RHR at discharge on 3-year cardiovascular outcomes following PCI and CABG for LMCAD. In the EXCEL trial, 1,905 patients with LMCAD were randomized to PCI with everolimus-eluting stents versus CABG. RHR was measured at discharge following the index hospitalization. The principal outcome measure was the composite endpoint of death, myocardial infarction (MI) or stroke at 3 years. Among 1,303 patients in sinus rhythm with available ECGs, the median (IQR) discharge RHR was 72 (62to 81) bpm. Median discharge RHR was higher after CABG versus PCI (78 [IQR 70 to 86] versus 65 [IQR 59 to 74] bpm, p <0.0001). At 3 years, 107 patients (8.2%) had a primary composite endpoint event including 61 patients (4.7%) who died. By multivariable analysis, discharge RHR assessed as a continuous variable (per 5 bpm) was an independent predictor at 3 years of the primary composite endpoint of death, MI, or stroke (hazard ratio [HR] 1.15, 95% confidence interval [CI] 1.06 to 1.25, p = 0.0006); the secondary composite endpoint of death, MI, stroke, or ischemia-driven revascularization at 3 years (HR 1.12, 95% CI 1.05 to 1.19, p = 0.0007); all-cause mortality (HR 1.18, 95% CI 1.07 to 1.31, p = 0.002); and cardiovascular death (HR 1.16, 95% CI 1.00 to 1.33, p = 0.046). No significant interactions were present between RHR and treatment with PCI versus CABG for the primary (pint = 0.20) or secondary (pint = 0.47) composite endpoints. In patients with LMCAD undergoing revascularization, an increased RHR at discharge was associated with a higher risk for adverse cardiovascular outcomes at 3 years, irrespective of treatment modality.
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Diamond J, Madhavan MV, Sabik JF, Serruys PW, Kappetein AP, Leon MB, Taggart DP, Berland J, Morice MC, Gersh BJ, Kandzari DE, Dressler O, Stone GW. Left Main Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Prior Cerebrovascular Disease: Results From the EXCEL Trial. JACC Cardiovasc Interv 2019; 11:2441-2450. [PMID: 30573053 DOI: 10.1016/j.jcin.2018.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/13/2018] [Accepted: 09/04/2018] [Indexed: 01/20/2023]
Abstract
OBJECTIVES The aim of this study was to determine whether high-risk patients with left main coronary artery disease (LMCAD) and prior cerebrovascular disease (CEVD) preferentially benefit from revascularization by percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG). BACKGROUND Patients with known CEVD requiring revascularization are often referred to PCI rather than CABG. There is a paucity of data regarding the impact of CEVD in patients with LMCAD undergoing revascularization. METHODS In the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, patients with LMCAD and low or intermediate SYNTAX (Synergy Between PCI with Taxus and Cardiac Surgery) scores were randomized to PCI with everolimus-eluting stents versus CABG. The effects of prior CEVD, defined as prior stroke, transient ischemic attack, or carotid artery disease, on 30-day and 3-year event rates were assessed. RESULTS Prior CEVD was present in 233 of 1,898 patients (12.3%). These patients were older and had higher rates of comorbidities, including hypertension, diabetes, peripheral vascular disease, anemia, chronic kidney disease, and prior PCI, compared with those without prior CEVD. Patients with prior CEVD had higher rates of stroke at 30 days (2.2% vs. 0.8%; p = 0.05) and 3 years (6.4% vs. 2.2%; p = 0.0003) and higher 3-year rates of the primary endpoint of all-cause death, stroke, or myocardial infarction (25.0% vs. 13.6%; p < 0.0001). The relative effects of PCI versus CABG on the 30-day and 3-year rates of stroke (pinteraction = 0.65 and 0.16, respectively) and the 3-year rates of the primary composite endpoint (pinteraction = 0.14) were consistent in patients with and those without prior CEVD. CONCLUSIONS Patients with LMCAD and prior CEVD compared with those without CEVD have higher rates of stroke and reduced event-free survival after revascularization. Data from the EXCEL trial do not a priori support a preferential role of PCI over CABG in patients with known CEVD.
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Affiliation(s)
- Jamie Diamond
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Mahesh V Madhavan
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Joseph F Sabik
- Department of Surgery, UH Cleveland Medical Center, Cleveland, Ohio
| | - Patrick W Serruys
- Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Arie Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Martin B Leon
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | | | | | - Marie-Claude Morice
- Ramsay Générale de Santé - Institut Cardiovasculaire Paris Sud, Massy, France
| | | | | | - Ovidiu Dressler
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Gregg W Stone
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York.
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Gershlick AH, Kandzari DE, Banning A, Taggart DP, Morice MC, Lembo NJ, Brown WM, Banning AP, Merkely B, Horkay F, van Boven AJ, Boonstra PW, Dressler O, Sabik JF, Serruys PW, Kappetein AP, Stone GW. Outcomes After Left Main Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting According to Lesion Site: Results From the EXCEL Trial. JACC Cardiovasc Interv 2019; 11:1224-1233. [PMID: 29976358 DOI: 10.1016/j.jcin.2018.03.040] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 03/27/2018] [Indexed: 01/02/2023]
Abstract
OBJECTIVES The authors sought to determine the extent to which the site of the left main coronary artery (LM) lesion (distal bifurcation versus ostial/shaft) influences the outcomes of revascularization with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). BACKGROUND Among 1,905 patients with LM disease and site-assessed SYNTAX scores of <32 randomized in the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, revascularization with PCI and CABG resulted in similar rates of the composite primary endpoint of death, myocardial infarction (MI), or stroke at 3 years. METHODS Outcomes from the randomized EXCEL trial were analyzed according to the presence of angiographic core laboratory-determined diameter stenosis ≥50% involving the distal LM bifurcation (n = 1,559; 84.2%) versus disease isolated to the LM ostium or shaft (n = 293; 15.8%). RESULTS At 3 years, there were no significant differences between PCI and CABG for the primary composite endpoint of death, MI, or stroke for treatment of both distal LM bifurcation disease (15.6% vs. 14.9%, odds ratio [OR]: 1.08, 95% confidence interval [CI]: 0.81 to 1.42; p = 0.61) and isolated LM ostial/shaft disease (12.4% vs. 13.5%, OR: 0.90, 95% CI: 0.45 to 1.81; p = 0.77) (pinteraction = 0.65). However, at 3 years, ischemia-driven revascularization occurred more frequently after PCI than CABG in patients with LM distal bifurcation disease (13.0% vs. 7.2%, OR: 2.00, 95% CI: 1.41 to 2.85; p = 0.0001), but were not significantly different in patients with disease only at the LM ostium or shaft (9.7% vs. 8.4%, OR: 1.18, 95% CI: 0.52 to 2.69; p = 0.68) (pinteraction = 0.25). CONCLUSIONS In the EXCEL trial, PCI and CABG resulted in comparable rates of death, MI, or stroke at 3 years for treatment of LM disease, including those with distal LM bifurcation disease. Repeat revascularization rates during follow-up after PCI compared with CABG were greater for lesions in the distal LM bifurcation but were similar for disease isolated to the LM ostium or shaft.
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Affiliation(s)
- Anthony H Gershlick
- University Hospitals of Leicester, University of Leicester, Leicester Biomedical Research Centre, Leicester, United Kingdom.
| | | | - Amerjeet Banning
- University Hospitals of Leicester, University of Leicester, Leicester Biomedical Research Centre, Leicester, United Kingdom
| | - David P Taggart
- Department of Cardiac Surgery, John Radcliffe Hospital, Oxford, United Kingdom
| | | | - Nicholas J Lembo
- Piedmont Heart Institute, Atlanta, Georgia; Center for Interventional Vascular Therapy, Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | | | - Adrian P Banning
- Department of Cardiac Surgery, John Radcliffe Hospital, Oxford, United Kingdom
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Ferenc Horkay
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | | | - Ovidiu Dressler
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Joseph F Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Patrick W Serruys
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | - Gregg W Stone
- Center for Interventional Vascular Therapy, Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
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35
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Stone GW, Kappetein AP, Sabik JF, Pocock SJ, Morice MC, Puskas J, Kandzari DE, Karmpaliotis D, Brown WM, Lembo NJ, Banning A, Merkely B, Horkay F, Boonstra PW, van Boven AJ, Ungi I, Bogáts G, Mansour S, Noiseux N, Sabaté M, Pomar J, Hickey M, Gershlick A, Buszman PE, Bochenek A, Schampaert E, Pagé P, Modolo R, Gregson J, Simonton CA, Mehran R, Kosmidou I, Généreux P, Crowley A, Dressler O, Serruys PW. Five-Year Outcomes after PCI or CABG for Left Main Coronary Disease. N Engl J Med 2019; 381:1820-1830. [PMID: 31562798 DOI: 10.1056/nejmoa1909406] [Citation(s) in RCA: 455] [Impact Index Per Article: 91.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Long-term outcomes after percutaneous coronary intervention (PCI) with contemporary drug-eluting stents, as compared with coronary-artery bypass grafting (CABG), in patients with left main coronary artery disease are not clearly established. METHODS We randomly assigned 1905 patients with left main coronary artery disease of low or intermediate anatomical complexity (according to assessment at the participating centers) to undergo either PCI with fluoropolymer-based cobalt-chromium everolimus-eluting stents (PCI group, 948 patients) or CABG (CABG group, 957 patients). The primary outcome was a composite of death, stroke, or myocardial infarction. RESULTS At 5 years, a primary outcome event had occurred in 22.0% of the patients in the PCI group and in 19.2% of the patients in the CABG group (difference, 2.8 percentage points; 95% confidence interval [CI], -0.9 to 6.5; P = 0.13). Death from any cause occurred more frequently in the PCI group than in the CABG group (in 13.0% vs. 9.9%; difference, 3.1 percentage points; 95% CI, 0.2 to 6.1). In the PCI and CABG groups, the incidences of definite cardiovascular death (5.0% and 4.5%, respectively; difference, 0.5 percentage points; 95% CI, -1.4 to 2.5) and myocardial infarction (10.6% and 9.1%; difference, 1.4 percentage points; 95% CI, -1.3 to 4.2) were not significantly different. All cerebrovascular events were less frequent after PCI than after CABG (3.3% vs. 5.2%; difference, -1.9 percentage points; 95% CI, -3.8 to 0), although the incidence of stroke was not significantly different between the two groups (2.9% and 3.7%; difference, -0.8 percentage points; 95% CI, -2.4 to 0.9). Ischemia-driven revascularization was more frequent after PCI than after CABG (16.9% vs. 10.0%; difference, 6.9 percentage points; 95% CI, 3.7 to 10.0). CONCLUSIONS In patients with left main coronary artery disease of low or intermediate anatomical complexity, there was no significant difference between PCI and CABG with respect to the rate of the composite outcome of death, stroke, or myocardial infarction at 5 years. (Funded by Abbott Vascular; EXCEL ClinicalTrials.gov number, NCT01205776.).
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Affiliation(s)
- Gregg W Stone
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - A Pieter Kappetein
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Joseph F Sabik
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Stuart J Pocock
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Marie-Claude Morice
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - John Puskas
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - David E Kandzari
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Dimitri Karmpaliotis
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - W Morris Brown
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Nicholas J Lembo
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Adrian Banning
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Béla Merkely
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Ferenc Horkay
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Piet W Boonstra
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Ad J van Boven
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Imre Ungi
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Gabor Bogáts
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Samer Mansour
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Nicolas Noiseux
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Manel Sabaté
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Jose Pomar
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Mark Hickey
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Anthony Gershlick
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Pawel E Buszman
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Andrzej Bochenek
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Erick Schampaert
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Pierre Pagé
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Rodrigo Modolo
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - John Gregson
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Charles A Simonton
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Roxana Mehran
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Ioanna Kosmidou
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Philippe Généreux
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Aaron Crowley
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Ovidiu Dressler
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
| | - Patrick W Serruys
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai (G.W.S., R. Mehran), the Cardiovascular Research Foundation (G.W.S., D.K., N.J.L., R. Mehran, I.K., P.G., A.C., O.D.), Mount Sinai Heart at Mount Sinai Saint Luke's (J. Puskas), and New York-Presbyterian Hospital and Columbia University Medical Center (D.K., N.J.L., I.K.) - all in New York; Erasmus Medical Center, Rotterdam (A.P.K.), Medisch Centrum Leeuwarden, Leeuwarden (P.W.B., A.J.B.), and Academic Medical Center, University of Amsterdam, Amsterdam (R. Modolo) - all in the Netherlands; University Hospitals Cleveland Medical Center, Cleveland (J.F.S.); the London School of Hygiene and Tropical Medicine (S.J.P., J.G.) and the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London (P.W.S.), London, John Radcliffe Hospital, Oxford (A. Banning), and University Hospitals of Leicester NHS Trust, Leicester (M.H., A.G.) - all in the United Kingdom; Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France (M.-C.M.); Piedmont Heart Institute, Atlanta (D.E.K., W.M.B.); Semmelweis University, Budapest (B.M., F.H.), and the University of Szeged, Szeged (I.U., G.B.) - both in Hungary; Centre Hospitalier de l'Université de Montréal (S.M., N.N.) and Hôpital du Sacré-Coeur de Montréal (E.S., P.P., P.G.), Montreal; Hospital Clinic, Barcelona (M.S., J. Pomar); Medical University of Silesia, Katowice, and American Heart of Poland, Ustron - both in Poland (P.E.B., A. Bochenek); University of Campinas, Campinas, Brazil (R. Modolo); Abbott Vascular, Santa Clara, CA (C.A.S.); and Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.)
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Kandzari DE, Gershlick AH, Serruys PW, Leon MB, Morice MC, Simonton CA, Lembo NJ, Banning AP, Merkely B, van Boven AJ, Ungi I, Kappetein AP, Sabik JF, Généreux P, Dressler O, Stone GW. Outcomes Among Patients Undergoing Distal Left Main Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2019; 11:e007007. [PMID: 30354633 DOI: 10.1161/circinterventions.118.007007] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Distal left main (LM) coronary artery bifurcation disease increases percutaneous coronary intervention (PCI) procedural complexity and is associated with worse outcomes than isolated ostial/shaft disease. The optimal treatment strategy for distal LM disease is undetermined. We sought to determine whether outcomes after PCI of LM distal bifurcation lesions are influenced by treatment with a provisional 1-stent versus planned 2-stent technique, and if so, whether such differences are conditioned by the complexity of the LM bifurcation lesion. METHODS AND RESULTS The clinical and angiographic characteristics, procedural methods and outcomes, and clinical events through 3-year follow-up were compared in patients undergoing distal LM PCI with a 1-stent provisional versus planned 2-stent technique in the EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization). Among 529 patients undergoing planned distal LM PCI, 344 (65.0%) and 185 (35.0%) were treated with intended 1-stent provisional and planned 2-stent techniques, respectively. The primary composite end point rate of death, myocardial infarction, or stroke at 3 years was significantly lower in patients treated with the provisional 1-stent versus planned 2-stent method (14.1% versus 20.7%; adjusted hazard ratio, 0.55; 95% CI, 0.35-0.88; P=0.01), driven by differences in cardiovascular death (3.3% versus 8.3%, P=0.01) and myocardial infarction (7.7% versus 12.8%, P=0.06). The 3-year rate of ischemia-driven revascularization of the LM complex was also lower in the provisional group (7.2% versus 16.3%, P=0.001). In 342 patients with distal LM bifurcation disease that did not involve both major side branch vessels, the 3-year primary end point was lower with a provisional 1-stent versus planned 2-stent technique (13.8% versus 23.3%, P=0.04), whereas no significant difference was present in 182 patients with distal LM bifurcation disease that did involve both side branch vessels (14.3% versus 19.2%, P=0.36). CONCLUSIONS Among patients with distal LM bifurcation disease in the EXCEL trial randomized to PCI, 3-year adverse outcomes were worse with planned 2-stent treatment compared with a provisional 1-stent approach, a difference that was confined to patients without major involvement of both LM side branch vessels. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT01205776.
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Affiliation(s)
| | - Anthony H Gershlick
- Leicester Biomedical Research Centre, University Hospitals of Leicester, University of Leicester, United Kingdom (A.H.G.)
| | - Patrick W Serruys
- Imperial College of Science, Technology and Medicine, London, United Kingdom (P.W.S.)
| | - Martin B Leon
- Center for Interventional Vascular Therapy, Division of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center (M.B.L., N.J.L., G.W.S.).,Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (M.B.L., N.J.L., P.G., O.D., G.W.S.)
| | - Marie-Claude Morice
- Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, Massy, France (M.-C.M.)
| | | | - Nicholas J Lembo
- Center for Interventional Vascular Therapy, Division of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center (M.B.L., N.J.L., G.W.S.).,Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (M.B.L., N.J.L., P.G., O.D., G.W.S.)
| | | | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.)
| | | | - Imre Ungi
- Cardiology Center, University of Szeged, Hungary (I.U.)
| | | | - Joseph F Sabik
- Department of Surgery, UH Cleveland Medical Center, OH (J.F.S.)
| | - Philippe Généreux
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (M.B.L., N.J.L., P.G., O.D., G.W.S.).,Gagnon Cardiovascular Institute, Morristown Medical Center, NJ (P.G.).,Hôpital du Sacré-Coeur de Montréal, Québec, Canada (P.G.)
| | - Ovidiu Dressler
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (M.B.L., N.J.L., P.G., O.D., G.W.S.)
| | - Gregg W Stone
- Center for Interventional Vascular Therapy, Division of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center (M.B.L., N.J.L., G.W.S.).,Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (M.B.L., N.J.L., P.G., O.D., G.W.S.)
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37
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Shlofmitz E, Généreux P, Chen S, Dressler O, Ben-Yehuda O, Morice MC, Puskas JD, Taggart DP, Kandzari DE, Crowley A, Redfors B, Mehdipoor G, Kappetein AP, Sabik JF, Serruys PW, Stone GW. Left Main Coronary Artery Disease Revascularization According to the SYNTAX Score. Circ Cardiovasc Interv 2019; 12:e008007. [DOI: 10.1161/circinterventions.118.008007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score (SS), a measure of anatomic coronary artery disease (CAD) extent and complexity, has proven useful in past studies to determine the absolute and relative prognosis after revascularization with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). We sought to assess contemporary outcomes after PCI and CABG in patients with left main CAD according to SS and revascularization type from a large randomized trial.
Methods:
The EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) randomized patients with left main CAD and site-assessed SS≤32 to PCI with everolimus-eluting stents or CABG. Four-year outcomes were examined according to angiographic core laboratory–assessed SS using multivariable Cox proportional hazards regression.
Results:
A total of 1840 patients with left main CAD randomized to PCI (n=914) versus CABG (n=926) had angiographic core laboratory SS assessment. The mean SS was 26.5±9.3 (range 5–74); 24.1% of patients had angiographic core laboratory–assessed SS ≥33. The 4-year rate of the primary major adverse cardiac event end point of death, stroke, or myocardial infarction was similar between PCI and CABG (18.6% versus 16.7%, respectively;
P
=0.40) and did not vary according to SS (
P
interaction
=0.33). Rates of ischemia-driven revascularization rose with increasing SS after PCI, but not after CABG. As a result, the major secondary composite end point of major adverse cardiac or cerebrovascular events (major adverse cardiac event or ischemia-driven revascularization) occurred more frequently with PCI than CABG (28.0% versus 22.0%,
P
=0.01), a difference which rose progressively with increasing SS (
P
interaction
=0.03).
Conclusions:
In the EXCEL trial, the 4-year primary composite major adverse cardiac event end point of death, myocardial infarction, or stroke was similar after PCI with everolimus-eluting stents and CABG and was independent of the baseline anatomic complexity and extent of CAD. In contrast, the relative and absolute hazard of major adverse cardiac or cerebrovascular events with PCI compared with CABG rose progressively with the SS. These data should be considered by the heart team when deciding between PCI versus CABG for revascularization in patients with left main CAD.
Clinical Trial Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier NCT01205776.
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Affiliation(s)
- Evan Shlofmitz
- Cardiovascular Research Foundation, NY (E.S., P.G., S.C., O.D., O.B.-Y., A.C., B.R., G.M., G.W.S.)
- New York-Presbyterian Hospital/Columbia University Medical Center (E.S., O.B.-Y., G.W.S.)
| | - Philippe Généreux
- Cardiovascular Research Foundation, NY (E.S., P.G., S.C., O.D., O.B.-Y., A.C., B.R., G.M., G.W.S.)
- Morristown Medical Center, NJ (P.G.)
- Hôpital du Sacré-Coeur de Montréal, Québec, Canada (P.G.)
| | - Shmuel Chen
- Cardiovascular Research Foundation, NY (E.S., P.G., S.C., O.D., O.B.-Y., A.C., B.R., G.M., G.W.S.)
| | - Ovidiu Dressler
- Cardiovascular Research Foundation, NY (E.S., P.G., S.C., O.D., O.B.-Y., A.C., B.R., G.M., G.W.S.)
| | - Ori Ben-Yehuda
- Cardiovascular Research Foundation, NY (E.S., P.G., S.C., O.D., O.B.-Y., A.C., B.R., G.M., G.W.S.)
- New York-Presbyterian Hospital/Columbia University Medical Center (E.S., O.B.-Y., G.W.S.)
| | - Marie-Claude Morice
- Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Massy, France (M.-C.M.)
| | | | | | | | - Aaron Crowley
- Cardiovascular Research Foundation, NY (E.S., P.G., S.C., O.D., O.B.-Y., A.C., B.R., G.M., G.W.S.)
| | - Björn Redfors
- Cardiovascular Research Foundation, NY (E.S., P.G., S.C., O.D., O.B.-Y., A.C., B.R., G.M., G.W.S.)
- Sahlgrenska University Hospital, Gothenburg, Sweden (B.R.)
| | - Ghazaleh Mehdipoor
- Cardiovascular Research Foundation, NY (E.S., P.G., S.C., O.D., O.B.-Y., A.C., B.R., G.M., G.W.S.)
| | | | | | | | - Gregg W. Stone
- Cardiovascular Research Foundation, NY (E.S., P.G., S.C., O.D., O.B.-Y., A.C., B.R., G.M., G.W.S.)
- New York-Presbyterian Hospital/Columbia University Medical Center (E.S., O.B.-Y., G.W.S.)
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38
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Benedetto U, Puskas J, Kappetein AP, Brown WM, Horkay F, Boonstra PW, Bogáts G, Noiseux N, Dressler O, Angelini GD, Stone GW, Serruys PW, Sabik JF, Taggart DP. Off-Pump Versus On-Pump Bypass Surgery for Left Main Coronary Artery Disease. J Am Coll Cardiol 2019; 74:729-740. [PMID: 31395122 DOI: 10.1016/j.jacc.2019.05.063] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 05/13/2019] [Accepted: 05/29/2019] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
| | - John Puskas
- Mount Sinai Saint Luke's Hospital, New York, New York
| | | | | | | | | | | | | | | | | | - Gregg W Stone
- Cardiovascular Research Foundation, New York, New York; Columbia University Medical Center, New York, New York. https://twitter.com/GreggWStone
| | - Patrick W Serruys
- International Centre for Circulatory Health, NHLI, Imperial College London, London, United Kingdom
| | - Joseph F Sabik
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
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39
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Chen S, Karmpaliotis D, Redfors B, Shlofmitz E, Ben-Yehuda O, Crowley A, Mehdipoor G, Puskas JD, Kandzari DE, Banning AP, Morice MC, Taggart DP, Sabik JF, Serruys PW, Kappetein AP, Stone GW. Does an occluded RCA affect prognosis in patients undergoing PCI or CABG for left main coronary artery disease? Analysis from the EXCEL trial. EUROINTERVENTION 2019; 15:e531-e538. [PMID: 31186220 DOI: 10.4244/eij-d-19-00263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The impact of an occluded right coronary artery (RCA) in patients with left main coronary artery disease (LMCAD) undergoing revascularisation is unknown. We compared outcomes for patients with LMCAD randomised to percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) according to the presence of an occluded RCA in the EXCEL trial. METHODS AND RESULTS The EXCEL trial randomised 1,905 patients with LMCAD and SYNTAX scores ≤32 to PCI with everolimus-eluting stents versus CABG. Patients were categorised according to whether they had an occluded RCA at baseline, and their outcomes were examined using multivariable Cox proportional hazards regression. The primary endpoint was a composite of death, stroke, or myocardial infarction at three years. Among 1,753 patients with a dominant RCA by core laboratory analysis, the RCA was occluded in 130 (7.4%) at baseline. PCI was attempted in 34 of 65 patients with an occluded RCA (52.3%) and was successful in 27 (79.4% of those attempted; 41.5% of all RCAs recanalised). The RCA was bypassed in 42 of 65 patients with an occluded RCA (64.6%; p=0.0008 versus PCI). The three-year absolute and relative rates of the primary endpoint were similar between PCI and CABG, in patients with or without an occluded RCA (pinteraction=0.92). CONCLUSIONS In the EXCEL trial, the presence of an occluded RCA at baseline did not confer a worse three-year prognosis in patients undergoing revascularisation for LMCAD and did not affect the relative outcomes of PCI versus CABG in this high-risk patient cohort.
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Affiliation(s)
- Shmuel Chen
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
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40
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Doucet S, Jolicœur EM, Serruys PW, Ragosta M, Kron IL, Scholtz W, Börgermann J, Zhang Y, McAndrew T, Sabik JF, Kappetein AP, Stone GW. Outcomes of left main revascularization in patients with acute coronary syndromes and stable ischemic heart disease: Analysis from the EXCEL trial. Am Heart J 2019; 214:9-17. [PMID: 31150791 DOI: 10.1016/j.ahj.2019.04.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 04/25/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Prompt revascularization is often required in acute coronary syndromes (ACS), whereas stable ischemic heart disease (SIHD) may allow for more measured procedural planning. Whether the acuity of presentation preferentially affects outcomes after coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in patients with left main coronary artery disease (LMCAD) is unknown. We investigated whether the acuity of presentation discriminated patients who derived a differential benefit from PCI versus CABG in the randomized Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial. METHODS We used multivariable Cox models to assess the interaction between the acuity of presentation, type of revascularization and outcomes in patients with low or intermediate SYNTAX scores enrolled in EXCEL. RESULTS At baseline, 1151 patients (60.7%) presented with SIHD and 746 patients (39.3%) presented with an ACS. The acuity of presentation was not associated with the primary endpoint of all-cause death, MI, or stroke at 3 years (multivariable adjusted hazard ratio [HR] 0.94; 95% CI 0.70-1.26, P = .64). The primary endpoint rate was similar in patients assigned to PCI versus CABG whether they presented with SIHD (adjusted HR 1.04; 95% CI 0.73-1.48]) or with ACS (HR 0.82; 95% CI 0.54-1.26) (Pinteraction = .34). CONCLUSIONS The acuity of presentation did not predict outcomes in patients with LMCAD undergoing revascularization, nor did it discriminate patients who derive greater event-free survival from PCI versus CABG.
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Affiliation(s)
- Serge Doucet
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Canada
| | - E Marc Jolicœur
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Canada
| | - Patrick W Serruys
- Imperial College of Science, Technology and Medicine, London, United Kingdom
| | | | - Irving L Kron
- University of Virginia Health System, Charlottesville, VA
| | - Werner Scholtz
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, University Hospital of the Ruhr-University of Bochum, Bad Oeynhausen, Germany
| | - Jochen Börgermann
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, University Hospital of the Ruhr-University of Bochum, Bad Oeynhausen, Germany
| | - Yiran Zhang
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY
| | - Thomas McAndrew
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY
| | - Joseph F Sabik
- Department of Surgery, UH Cleveland Medical Center, Cleveland, OH
| | | | - Gregg W Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY; Center for Interventional Vascular Therapy, Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY.
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41
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Kosmidou I, Chen S, Kappetein AP, Serruys PW, Gersh BJ, Puskas JD, Kandzari DE, Taggart DP, Morice MC, Buszman PE, Bochenek A, Schampaert E, Pagé P, Sabik JF, McAndrew T, Redfors B, Ben-Yehuda O, Stone GW. New-Onset Atrial Fibrillation After PCI or CABG for Left Main Disease: The EXCEL Trial. J Am Coll Cardiol 2019; 71:739-748. [PMID: 29447735 DOI: 10.1016/j.jacc.2017.12.012] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 11/29/2017] [Accepted: 12/08/2017] [Indexed: 11/25/2022]
Abstract
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).
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Affiliation(s)
- Ioanna Kosmidou
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Arrhythmia Center, Department of Cardiology, St. Francis Hospital, Roslyn, New York
| | - Shmuel Chen
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | | | - Patrick W Serruys
- Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - John D Puskas
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - David P Taggart
- Department Cardiac Surgery, John Radcliffe Hospital, Oxford, United Kingdom
| | - Marie-Claude Morice
- Ramsay Générale de Santé, Institut Cardiovasculaire Paris Sud, Paris, France
| | - Paweł E Buszman
- Medical University of Silesia, Katowice, Poland; American Heart of Poland, Ustron, Poland
| | - Andrzej Bochenek
- Medical University of Silesia, Katowice, Poland; American Heart of Poland, Ustron, Poland
| | | | - Pierre Pagé
- Hôpital du Sacré-Coeur de Montréal, Montréal, Canada
| | - Joseph F Sabik
- Department of Surgery, UH Cleveland Medical Center, Cleveland, Ohio
| | - Thomas McAndrew
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Ori Ben-Yehuda
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Gregg W Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York.
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42
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Milojevic M, Serruys PW, Sabik JF, Kandzari DE, Schampaert E, van Boven AJ, Horkay F, Ungi I, Mansour S, Banning AP, Taggart DP, Sabaté M, Gershlick AH, Bochenek A, Pomar J, Lembo NJ, Noiseux N, Puskas JD, Crowley A, Kosmidou I, Mehran R, Ben-Yehuda O, Généreux P, Pocock SJ, Simonton CA, Stone GW, Kappetein AP. Bypass Surgery or Stenting for Left Main Coronary Artery Disease in Patients With Diabetes. J Am Coll Cardiol 2019; 73:1616-1628. [DOI: 10.1016/j.jacc.2019.01.037] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 01/01/2019] [Indexed: 12/22/2022]
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43
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Kosmidou I, Redfors B, Chen S, Crowley A, Lembo NJ, Karmpaliotis D, Brown WM, Maupas E, Durrleman N, Shah A, Reardon MJ, Dressler O, Ben-Yehuda O, Kappetein AP, Sabik JF, Serruys PW, Stone GW. C-reactive protein and prognosis after percutaneous coronary intervention and bypass graft surgery for left main coronary artery disease: Analysis from the EXCEL trial. Am Heart J 2019; 210:49-57. [PMID: 30738244 DOI: 10.1016/j.ahj.2018.12.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 12/19/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND The prognostic impact of high-sensitivity C-reactive protein (CRP) levels in patients with left main coronary artery disease (LMCAD) treated with percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) is unknown. We sought to determine the effect of elevated baseline CRP levels on the 3-year outcomes after LMCAD revascularization and to examine whether CRP influenced the relative outcomes of PCI versus CABG. METHODS In the EXCEL trial, patients with LMCAD and Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) scores ≤32 were randomized to PCI versus CABG. The primary composite outcome of death, myocardial infarction (MI), or stroke was analyzed according to baseline CRP levels. RESULTS Among 999 patients with available CRP levels, median CRP was 3.10 mg/L (interquartile range 1.12-6.40 mg/L). The rate of the primary composite end point of death, MI, or stroke at 3 years steadily increased with greater baseline CRP levels. The adjusted relationship between the 3-year composite rate of death, MI, or stroke and baseline CRP modeled as a continuous log-transformed variable demonstrated steadily increasing event rates with greater CRP levels (adjusted hazard ratio, 1.26, 95% CI 1.10-1.44, P = .0008). Similarly, patients with CRP ≥10 mg/L had a 3-fold higher risk of the 3-year primary end point compared to patients with lower CRP levels (adjusted hazard ratio 2.92, 95% CI 1.88-4.54, P < .0001). The association between an elevated CRP level and the adjusted 3-year risk of the primary composite end point did not differ according to revascularization strategy (Pinteraction = .75). CONCLUSIONS In patients with LMCAD undergoing revascularization, elevated baseline CRP levels were strongly associated with subsequent death, MI, and stroke at 3 years, irrespective of the mode of revascularization. Further studies are warranted to determine whether anti-inflammatory therapies may improve the prognosis of high-risk patients with LMCAD following revascularization.
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Affiliation(s)
- Ioanna Kosmidou
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY; NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY
| | - Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY
| | - Shmuel Chen
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY
| | - Aaron Crowley
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY
| | - Nicholas J Lembo
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY; NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY
| | - Dimitri Karmpaliotis
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY; NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY
| | | | - Eric Maupas
- Hôpital Privé Les Franciscaines, Nîmes, France
| | | | | | | | - Ovidiu Dressler
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY
| | - Ori Ben-Yehuda
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY; NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY
| | | | - Joseph F Sabik
- Department of Surgery, UH Cleveland Medical Center, Cleveland, OH
| | - Patrick W Serruys
- Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Gregg W Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY; NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY.
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44
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Ben-Yehuda O, Chen S, Redfors B, McAndrew T, Crowley A, Kosmidou I, Kandzari DE, Puskas JD, Morice MC, Taggart DP, Leon MB, Lembo NJ, Brown WM, Simonton CA, Dressler O, Kappetein AP, Sabik JF, Serruys PW, Stone GW. 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. Eur Heart J 2019; 40:1930-1941. [DOI: 10.1093/eurheartj/ehz113] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 10/04/2018] [Accepted: 03/06/2019] [Indexed: 01/06/2023] Open
Affiliation(s)
- Ori Ben-Yehuda
- Clinical Trials Center, Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY, USA
- Division of Cardiology, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Shmuel Chen
- Clinical Trials Center, Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY, USA
| | - Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY, USA
| | - Thomas McAndrew
- Clinical Trials Center, Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY, USA
| | - Aaron Crowley
- Clinical Trials Center, Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY, USA
| | - Ioanna Kosmidou
- Clinical Trials Center, Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY, USA
- Department of Cardiology, St. Francis Hospital, Roslyn, NY, USA
| | | | - John D Puskas
- Mount Sinai Heart at Mount Sinai Saint Luke’s, New York, NY, USA
| | | | - David P Taggart
- Department Cardiac Surgery, John Radcliffe Hospital, Oxford, UK
| | - Martin B Leon
- Clinical Trials Center, Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY, USA
- Division of Cardiology, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Nicholas J Lembo
- Clinical Trials Center, Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY, USA
- Division of Cardiology, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | | | | | - Ovidiu Dressler
- Clinical Trials Center, Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY, USA
| | | | - Joseph F Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Gregg W Stone
- Clinical Trials Center, Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY, USA
- Division of Cardiology, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
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45
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Outcomes of patients with and without baseline lipid-lowering therapy undergoing revascularization for left main coronary artery disease: analysis from the EXCEL trial. Coron Artery Dis 2018; 30:143-149. [PMID: 30531253 DOI: 10.1097/mca.0000000000000688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES There is a paucity of data on the effect of baseline lipid-lowering therapy (LLT) in patients undergoing revascularization for left main (LM) coronary artery disease (CAD). We compared outcomes for patients with LMCAD randomized to percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) according to the presence of baseline LLT in the EXCEL trial. PATIENTS AND METHODS The EXCEL trial randomized 1905 patients with LMCAD and SYNTAX scores up to 32 to PCI with everolimus-eluting stents versus CABG. Patients were categorized according to whether they were medically treated with LLT at baseline, and their outcomes were examined using multivariable Cox proportional hazards regression. The primary endpoint was a composite of death, stroke, or myocardial infarction at 3 years. RESULTS Among 1901 patients with known baseline LLT status, 1331 (70.0%) were medically treated with LLT at baseline. There were no significant differences between the PCI and CABG groups in the 3-year rates of the primary endpoint in patients with versus without baseline LLT (Pinteraction=0.62). Among patients with baseline LLT, the 3-year rate of ischemia-driven revascularization was higher after PCI compared with CABG (13.7 vs. 5.3%; adjusted hazard ratio=2.97; 95% confidence interval: 1.95-4.55; P<0.0001), in contrast to patients without baseline LLT (9.8 vs. 12.1%; adjusted hazard ratio=0.79; 95% confidence interval: 0.47-1.33; P=0.39) (Pinteraction=0.0003). CONCLUSION In the EXCEL trial, 3-year major adverse event rates after PCI versus CABG for LMCAD were similar and consistent in patients with and without LLT at baseline; however, revascularization during follow-up was more common after PCI compared with CABG in patients with baseline LLT, but not in those without baseline LLT.
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46
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Giustino G, Mehran R, Serruys PW, Sabik JF, Milojevic M, Simonton CA, Puskas JD, Kandzari DE, Morice MC, Taggart DP, Gershlick AH, Généreux P, Zhang Z, McAndrew T, Redfors B, Ragosta M, Kron IL, Dressler O, Leon MB, Pocock SJ, Ben-Yehuda O, Kappetein AP, Stone GW. Left Main Revascularization With PCI or CABG in Patients With Chronic Kidney Disease. J Am Coll Cardiol 2018; 72:754-765. [DOI: 10.1016/j.jacc.2018.05.057] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 04/26/2018] [Accepted: 05/11/2018] [Indexed: 01/22/2023]
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47
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Redfors B, Chen S, Crowley A, Ben-Yehuda O, Gersh BJ, Lembo NJ, Brown WM, Banning AP, Taggart DP, Serruys PW, Kappetein AP, Sabik JF, Stone GW. B-Type Natriuretic Peptide Assessment in Patients Undergoing Revascularization for Left Main Coronary Artery Disease. Circulation 2018; 138:469-478. [DOI: 10.1161/circulationaha.118.033631] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Elevated B-type natriuretic peptide (BNP) is reflective of impaired cardiac function and is associated with worse prognosis among patients with coronary artery disease (CAD). We sought to assess the association between baseline BNP, adverse outcomes, and the relative efficacy of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with left main CAD.
Methods:
The EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) randomized patients with left main CAD and low or intermediate SYNTAX scores (Synergy Between PCI With TAXUS and Cardiac Surgery) to PCI with everolimus-eluting stents versus CABG. The primary end point was the composite of all-cause death, myocardial infarction, or stroke. We used multivariable Cox proportional hazards regression to assess the associations between normal versus elevated BNP (≥100 pg/mL), randomized treatment, and the 3-year risk of adverse events.
Results:
BNP at baseline was elevated in 410 of 1037 (39.5%) patients enrolled in EXCEL. Patients with elevated BNP levels were older and more frequently had additional cardiovascular risk factors and lower left ventricular ejection fraction than those with normal BNP, but had similar SYNTAX scores. Patients with elevated BNP had significantly higher 3-year rates of the primary end point (18.6% versus 11.7%; adjusted hazard ratio [HR], 1.62; 95% confidence interval [CI], 1.16–2.28;
P
=0.005) and higher mortality (11.5% versus 3.9%; adjusted HR, 2.49; 95% CI, 1.48–4.19;
P
=0.0006), both from cardiovascular and noncardiovascular causes. In contrast, there were no significant differences in the risks of myocardial infarction, stroke, ischemia-driven revascularization, stent thrombosis, graft occlusion, or major bleeding. A significant interaction (
P
interaction
=0.03) was present between elevated versus normal BNP and treatment with PCI versus CABG for the adjusted risk of the primary composite end point at 3 years among patients with elevated BNP (adjusted HR for PCI versus CABG, 1.54; 95% CI, 0.96–2.47) versus normal BNP (adjusted HR, 0.74; 95% CI, 0.46–1.20). This interaction was stronger when log(BNP) was modeled as a continuous variable (
P
interaction
=0.002).
Conclusions:
In the EXCEL trial, elevated baseline BNP levels in patients with left main CAD undergoing revascularization were independently associated with long-term mortality but not nonfatal adverse ischemic or bleeding events. The relative long-term outcomes after PCI versus CABG for revascularization of left main CAD may be conditioned by the baseline BNP level.
Clinical Trial Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT01205776.
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Affiliation(s)
- Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., S.C., A.C., O.B.-Y., G.W.S.)
| | - Shmuel Chen
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., S.C., A.C., O.B.-Y., G.W.S.)
| | - Aaron Crowley
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., S.C., A.C., O.B.-Y., G.W.S.)
| | - Ori Ben-Yehuda
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., S.C., A.C., O.B.-Y., G.W.S.)
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY (O.B.-Y., N.J.L., G.W.S)
| | - Bernard J. Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN (B.J.G.)
| | - Nicholas J. Lembo
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY (O.B.-Y., N.J.L., G.W.S)
| | | | | | - David P. Taggart
- John Radcliffe Hospital, Oxford, United Kingdom (A.P.B., D.P.T.)
| | - Patrick W. Serruys
- Imperial College of Science, Technology and Medicine, London, United Kingdom (P.W.S.)
| | | | - Joseph F. Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, OH (J.F.S.)
| | - Gregg W. Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., S.C., A.C., O.B.-Y., G.W.S.)
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY (O.B.-Y., N.J.L., G.W.S)
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48
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Escaned J, Collet C, Ryan N, De Maria GL, Walsh S, Sabate M, Davies J, Lesiak M, Moreno R, Cruz-Gonzalez I, Hoole SP, Ej West N, Piek JJ, Zaman A, Fath-Ordoubadi F, Stables RH, Appleby C, van Mieghem N, van Geuns RJ, Uren N, Zueco J, Buszman P, Iñiguez A, Goicolea J, Hildick-Smith D, Ochala A, Dudek D, Hanratty C, Cavalcante R, Kappetein AP, Taggart DP, van Es GA, Morel MA, de Vries T, Onuma Y, Farooq V, Serruys PW, Banning AP. Clinical outcomes of state-of-the-art percutaneous coronary revascularization in patients with de novo three vessel disease: 1-year results of the SYNTAX II study. Eur Heart J 2018; 38:3124-3134. [PMID: 29020367 PMCID: PMC5837643 DOI: 10.1093/eurheartj/ehx512] [Citation(s) in RCA: 200] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 08/23/2017] [Indexed: 12/15/2022] Open
Abstract
Aims To investigate if recent technical and procedural developments in percutaneous coronary intervention (PCI) significantly influence outcomes in appropriately selected patients with three-vessel (3VD) coronary artery disease. Methods and results The SYNTAX II study is a multicenter, all-comers, open-label, single arm study that investigated the impact of a contemporary PCI strategy on clinical outcomes in patients with 3VD in 22 centres from four European countries. The SYNTAX-II strategy includes: heart team decision-making utilizing the SYNTAX Score II (a clinical tool combining anatomical and clinical factors), coronary physiology guided revascularisation, implantation of thin strut bioresorbable-polymer drug-eluting stents, intravascular ultrasound (IVUS) guided stent implantation, contemporary chronic total occlusion revascularisation techniques and guideline-directed medical therapy. The rate of major adverse cardiac and cerebrovascular events (MACCE [composite of all-cause death, cerebrovascular event, any myocardial infarction and any revascularisation]) at one year was compared to a predefined PCI cohort from the original SYNTAX-I trial selected on the basis of equipoise 4-year mortality between CABG and PCI. As an exploratory endpoint, comparisons were made with the historical CABG cohort of the original SYNTAX-I trial. Overall 708 patients were screened and discussed within the heart team; 454 patients were deemed appropriate to undergo PCI. At one year, the SYNTAX-II strategy was superior to the equipoise-derived SYNTAX-I PCI cohort (MACCE SYNTAX-II 10.6% vs. SYNTAX-I 17.4%; HR 0.58, 95% CI 0.39–0.85, P = 0.006). This difference was driven by a significant reduction in the incidence of MI (HR 0.27, 95% CI 0.11–0.70, P = 0.007) and revascularisation (HR 0.57, 95% CI 0.37–0.9, P = 0.015). Rates of all-cause death (HR 0.69, 95% CI 0.27–1.73, P = 0.43) and stroke (HR 0.69, 95% CI 0.10–4.89, P = 0.71) were similar. The rate of definite stent thrombosis was significantly lower in SYNTAX-II (HR 0.26, 95% CI 0.07–0.97, P = 0.045). Conclusion At one year, clinical outcomes with the SYNTAX-II strategy were associated with improved clinical results compared to the PCI performed in comparable patients from the original SYNTAX-I trial. Longer term follow-up is awaited and a randomized clinical trial with contemporary CABG is warranted. ClinicalTrials.gov Identifier NCT02015832
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Affiliation(s)
- Javier Escaned
- Hospital Cliinico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain; Calle Profesor Martín Lagos s/n, 28040 Madrid, Spain
| | - Carlos Collet
- Department of Cardiology, Academic Medical Center of Amsterdam, Cardiology, Amsterdam, the Netherlands; Meibergdreef 9, 1105 AZ Amsterdam-Zuidoost, the Netherlands
| | - Nicola Ryan
- Hospital Cliinico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain; Calle Profesor Martín Lagos s/n, 28040 Madrid, Spain
| | - Giovanni Luigi De Maria
- Department of Cardiology, John Radcliffe Hospital, Cardiology, Oxford, UK; Headley Way, Headington, Oxford OX3 9DU, UK
| | - Simon Walsh
- Department of Cardiology Belfast Health & Social Care Trust, Belfast, UK; Knockbracken Healthcare Park, Saintfield Rd, Belfast BT8 8BH, UK
| | - Manel Sabate
- Hospital Clinic I Provincial de Barcelona, Barcelona, Spain; Carrer de Villarroel, 170, 08036 Barcelona, Spain
| | - Justin Davies
- Department of Cardiology, Imperial College London, London, UK; Kensington, London SW7 2AZ, UK
| | - Maciej Lesiak
- 1st Department of Cardiology, University of Medical Sciences, Poznan, Poland; Collegium Maius, Fredry 10, 61-701 Poznan, Poland
| | - Raul Moreno
- Department of Cardiology, Hospital Universitario la Paz, Madrid, Spain; Paseo de la Castellana, 261, 28046 Madrid, Spain
| | - Ignacio Cruz-Gonzalez
- Department of Cardiology, Hospital Universitario de Salamanca, IBSAL, Salamanca, Spain; Paseo de San Vicente, 58, 37007 Salamanca, Spain
| | - Stephan P Hoole
- Department of Cardiology, Papworth Hospital NHS Foundation Trust, Cambridge, UK; Papworth Everard, Cambridge CB23 3RE, UK
| | - Nick Ej West
- Department of Cardiology, Papworth Hospital NHS Foundation Trust, Cambridge, UK; Papworth Everard, Cambridge CB23 3RE, UK
| | - J J Piek
- Department of Cardiology, Academic Medical Center of Amsterdam, Cardiology, Amsterdam, the Netherlands; Meibergdreef 9, 1105 AZ Amsterdam-Zuidoost, the Netherlands
| | - Azfar Zaman
- Department of Cardiology, Freeman Hospital and Newcastle University, Newcastle-upon-Tyne, UK; High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - Farzin Fath-Ordoubadi
- Manchester Heart Centre, Manchester Royal Infirmary, Central Manchester University Hospitals, Manchester, UK; Oxford Rd, Manchester M13 9WL, UK
| | - Rodney H Stables
- Liverpool Heart and Chest Hospital, Liverpool, UK; Thomas Dr, Liverpool L14 3PE, UK
| | - Clare Appleby
- Liverpool Heart and Chest Hospital, Liverpool, UK; Thomas Dr, Liverpool L14 3PE, UK
| | - Nicolas van Mieghem
- Thoraxcenter, Erasmus MC, the Netherlands; 's-Gravendijkwal 230, 3015 CE Rotterdam, the Netherlands
| | - Robert Jm van Geuns
- Thoraxcenter, Erasmus MC, the Netherlands; 's-Gravendijkwal 230, 3015 CE Rotterdam, the Netherlands
| | - Neal Uren
- The Royal Infirmary of Edinburgh, Edinburgh, UK; 51 Little France Dr, Edinburgh EH16 4SA, UK
| | - Javier Zueco
- Department of Cardiology, Hospital Universitario Valdecilla, Cantabria, Spain; Av. Valdecilla, 25, 39008 Santander, Cantabria, Spain
| | - Pawel Buszman
- American Heart of Poland (PAK), Ustrón, Poland; Sanatoryjna 1, 43-450 Ustrón, Poland
| | - Andres Iñiguez
- Department of Cardiology, Hospital Meixoeiro, Pontevedra, Spain; Camiño Meixoeiro, s/n, 36214 Vigo, Pontevedra, Spain
| | - Javier Goicolea
- Department of Cardiology, Hospital Meixoeiro, Pontevedra, Spain; Camiño Meixoeiro, s/n, 36214 Vigo, Pontevedra, Spain
| | - David Hildick-Smith
- Brighton & Sussex University Hospitals NHS Trust, Brighton, UK; Barry Building, Eastern Rd, Brighton BN2 5BE, UK
| | - Andrzej Ochala
- Gornoslaskie Centrum Medycnze, Poland; 45/47, 40-635 Katowice, Poland
| | - Dariusz Dudek
- Department of Interventional Cardiology, Jagiellonian University, Krakow, Poland; Gol?bia 24, 31-007 Kraków, Poland
| | - Colm Hanratty
- Department of Cardiology Belfast Health & Social Care Trust, Belfast, UK; Knockbracken Healthcare Park, Saintfield Rd, Belfast BT8 8BH, UK
| | - Rafael Cavalcante
- Thoraxcenter, Erasmus MC, the Netherlands; 's-Gravendijkwal 230, 3015 CE Rotterdam, the Netherlands
| | - Arie Pieter Kappetein
- Thoraxcenter, Erasmus MC, the Netherlands; 's-Gravendijkwal 230, 3015 CE Rotterdam, the Netherlands
| | - David P Taggart
- Department of Cardiology, John Radcliffe Hospital, Cardiology, Oxford, UK; Headley Way, Headington, Oxford OX3 9DU, UK
| | - Gerrit-Anne van Es
- Cardialysis BV, Rotterdam, the Netherlands; Westblaak 98, 3012 KM, Rotterdam, the Netherlands.,European Cardiovascular Research Institute, Westblaak 98, 3012 KM, Rotterdam, the Netherlands
| | - Marie-Angèle Morel
- Cardialysis BV, Rotterdam, the Netherlands; Westblaak 98, 3012 KM, Rotterdam, the Netherlands
| | - Ton de Vries
- Cardialysis BV, Rotterdam, the Netherlands; Westblaak 98, 3012 KM, Rotterdam, the Netherlands
| | - Yoshinobu Onuma
- Thoraxcenter, Erasmus MC, the Netherlands; 's-Gravendijkwal 230, 3015 CE Rotterdam, the Netherlands.,Cardialysis BV, Rotterdam, the Netherlands; Westblaak 98, 3012 KM, Rotterdam, the Netherlands
| | - Vasim Farooq
- Manchester Heart Centre, Manchester Royal Infirmary, Central Manchester University Hospitals, Manchester, UK; Oxford Rd, Manchester M13 9WL, UK
| | - Patrick W Serruys
- Department of Cardiology, Imperial College London, London, UK; Kensington, London SW7 2AZ, UK
| | - Adrian P Banning
- Department of Cardiology, John Radcliffe Hospital, Cardiology, Oxford, UK; Headley Way, Headington, Oxford OX3 9DU, UK
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49
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Outcomes After Coronary Stenting or Bypass Surgery for Men and Women With Unprotected Left Main Disease. JACC Cardiovasc Interv 2018; 11:1234-1243. [DOI: 10.1016/j.jcin.2018.03.051] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 03/19/2018] [Accepted: 03/27/2018] [Indexed: 01/24/2023]
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50
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Mahmood M, Altaf A, Salahuddin M, Khan M, Shah KA, Shah H. Prognosis of Percutaneous Intervention of a Left Main Coronary Artery Stenosis Without the Use of Intravascular Imaging. Cureus 2018; 10:e2857. [PMID: 30148010 PMCID: PMC6107041 DOI: 10.7759/cureus.2857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives The aim of this study was to assess the prognosis in patients with left main coronary artery stenosis one year after percutaneous coronary intervention (PCI). Methods Our study included 40 patients who underwent PCI for left main coronary artery stenosis without the use of intravascular ultrasound (IVUS). Patients were followed for a year, and the prognostic effect of PCI on a composite end-point of revascularization, new myocardial infarction, cardiac death, and on all-cause mortality was assessed in multivariable Cox analysis. Results The multivariable analysis showed a good prognosis in patients receiving PCI with a total event rate of 7.5%. The independent predictors for major adverse cardiac events (MACE) were diabetes (p = 0.02). Other prognostic factors included in the model were gender, age, smoking, body mass index (BMI), hypertension, the complexity of the vessel, and ejection fraction. Conclusion PCI for left main coronary artery stenosis without the use of IVUS has a good prognosis after one year of clinical follow-up.
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Affiliation(s)
- Mazhar Mahmood
- Department of Cardiology, Rehman Medical Institute, Peshawar, PAK
| | - Afrasyab Altaf
- Cardiology, Tongji Hospital of Tongji University, Shanghai, CHN
| | - Momin Salahuddin
- Department of Cardiology, Rehman Medical Institute, Peshawar, PAK
| | - Momin Khan
- Department of Cardiology, Rehman Medical Institute, Peshawar, PAK
| | - Karamat A Shah
- Department of Cardiology, Rehman Medical Institute, Peshawar, PAK
| | - Hammad Shah
- Department of Cardiology, Rehman Medical Institute, Peshawar, PAK
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