The Official Journal of EuroPCR and the European Association of Percutaneous Coronary Interventions (EAPCI)

Does an Occluded RCA Affect Prognosis in Patients Undergoing PCI or CABG for Left Main Coronary Artery Disease? Analysis From the EXCEL Trial

1. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
2. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA; NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
3. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
4. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA; NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
5. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA; NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
6. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
7. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
8. Mount Sinai Heart at Mount Sinai Saint Luke’s, New York, NY, USA
9. Piedmont Heart Institute, Atlanta, GA, USA
10. John Radcliffe Hospital, Oxford, United Kingdom
11. Ramsay Générale de Santé, Institut Cardiovasculaire Paris Sud, Paris, France
12. John Radcliffe Hospital, Oxford, United Kingdom
13. Department of Surgery, UH Cleveland Medical Center, Cleveland, OH, USA
14. Imperial College of Science, Technology and Medicine, London, United Kingdom
15. Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands
16. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA; New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
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Aims: The impact of an occluded right coronary artery (RCA) in patients with left main coronary artery disease (LMCAD) undergoing revascularization is unknown. We compared outcomes for patients with LMCAD randomized 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 randomized 1905 patients with LMCAD and SYNTAX scores ≤32 to PCI with everolimus-eluting stents versus CABG. Patients were categorized 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 3 years. Among 1753 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 recanalized). The RCA was bypassed in 42 of 65 patients with an occluded RCA (64.6%; p=0.0008 versus PCI). The 3-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 3-year prognosis in patients undergoing revascularization for LMCAD and did not affect the relative outcomes of PCI versus CABG in this high-risk patient cohort.

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