Quality of Life Between Surgery and Angioplasty for the Treatment of Left Main Disease

In recent years, angioplasty with drug-eluting stents (DES) has emerged as an alternative to myocardial revascularization surgery in patients with left main coronary artery disease. Both European and American guidelines offer a Class IIa recommendation for left main coronary artery (LMCA) angioplasty in selected patients.

The EXCEL (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial found similar rates of death, stroke, and acute myocardial infarction at 36 months in patients with left main disease treated with everolimus-eluting stent vs. surgery.

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Beyond the global results, the occurrence of certain events and their timing differed by treatment group. For example, patients who underwent surgery experienced higher rates of infarction within the first 30 days, while the rate of repeat revascularization at the end of the follow-up period was significantly higher for patients who underwent angioplasty. This study was designed to gain better understanding of the effects of both revascularization strategies from the patient’s perspective, as opposed to the traditional combined endpoint of death, infarction, and stroke.

Between September 2010 and March 2014, 1905 patients with left main disease were randomized to undergo surgery or angioplasty; 1788 of them participated in the quality of life substudy. Quality of life was assessed using different scores and tests (e.g., the Seattle Angina Questionnaire, among others) at baseline, 1, 12, and 36 months.

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At the end of the follow-up period, both revascularization strategies were associated with significant improvement from baseline. As expected, within the first month, angioplasty was associated with much better quality of life than surgery. However, this difference was largely attenuated by 12 months, and by the end of the follow-up, there were no significant differences whatsoever.

Conclusion

Among selected patients with left main coronary artery disease, both revascularization strategies resulted in significant improvement from baseline, although a greater early benefit was seen with angioplasty.

Taking into account the much harder results already published and the perspective of patients as assessed by this study, surgery and angioplasty appear to be similar for this selected patient subgroup.

Original title: Quality-of-Life After Everolimus-Eluting Stents or Bypass Surgery for Left-Main Disease. Results from the EXCEL Trial.

Reference: Suzanne J. Baron et al. J Am Coll Cardiol 2017;70:3113-22.

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