Coronary interventions

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. DOI: 10.4244/EIJ-D-19-00263

Shmuel Chen
Shmuel Chen1, MD, PhD; Dimitrios Karmpaliotis1,2, MD, PhD; Björn Redfors1,3, MD, PhD; Evan Shlofmitz1,2, DO; Ori Ben-Yehuda1,2, MD; Aaron Crowley1, MA; Ghazaleh Mehdipoor1, MD; John D. Puskas4, MD; David E. Kandzari5, MD; Adrian P. Banning6, MD; Marie-Claude Morice7, MD; David P. Taggart6, MD, PhD; Joseph F. Sabik 3rd8, MD; Patrick W. Serruys9, MD, PhD; A. Pieter Kappetein10, MD, PhD; Gregg W. Stone1,2, MD
1. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA; 2. NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA; 3. Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; 4. Mount Sinai Heart at Mount Sinai Saint Luke’s, New York, NY, USA; 5. Piedmont Heart Institute, Atlanta, GA, USA; 6. John Radcliffe Hospital, Oxford, United Kingdom; 7. Hôpital privé Jacques Cartier, Ramsay Générale de Santé, Massy, France; 8. Department of Surgery, UH Cleveland Medical Center, Cleveland, OH, USA; 9. Imperial College of Science, Technology and Medicine, London, United Kingdom; 10. Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands

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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drug-eluting stentmultiple vessel diseasechronic coronary total occlusion
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