According to the EXCEL trial, peri-procedural infarction was more common after left main coronary artery surgery compared with angioplasty, and it was strongly associated with increased 3-year mortality after controlling all possible confounding variables. This increased mortality was only present in extensive infarctions with an increase in CK-MB ≥10×.

The EXCEL trial seems to want to challenge the SYNTAX trial as far as the number of sub-studies goes. Month after month we find a new published article derived from EXCEL trial data.

This particular work examined the 3-year rates of mortality among patients with and without peri-procedural infarction in a setting of left main coronary artery revascularization, who were randomized to angioplasty with an everolimus-eluting stent or surgery in the large-scale, multicenter, prospective, randomized EXCEL trial.

Per protocol, identical criteria were specified to define peri-procedural infarction for both strategies: CK-MB elevation >10× the upper reference limit within 72 h after the procedure, or >5× with new Q-waves, angiographic vessel occlusion, or loss of myocardial mass on imaging.

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The sub-study included a total of 1858 patients; the number of patients who met the criteria for peri-procedural infarction was 34 out of 935 (3.6%) patients in the angioplasty group and 56 out of 923 (6.1%) patients in the surgery group (odds ratio: 0.61; 95% confidence interval [CI]: 0.40–0.93; p = 0.02).

Periprocedural infarction was associated with anatomical complexity (SYNTAX score), chronic obstructive pulmonary disease, cross-clamp duration and total procedure duration, and not using antegrade cardioplegia.

Peri-procedural infarction almost tripled the 3-year mortality rates (hazard ratio [HR]: 2.63; 95% CI: 1.19-5.81; p = 0.02). Such effect was consistent for both revascularization strategies.

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Peak post-procedure CK-MB ≥10× was clearly associated with mortality, whereas lesser degrees did not change the prognosis.

Conclusion

In the EXCEL trial, peri-procedural infarction was more common after surgery compared with angioplasty as treatment in the left main coronary artery, and it was strongly associated with increased 3-year mortality. Only extensive infarctions (CK-MB ≥10×) had an impact on prognosis.

Original title: Impact of large periprocedural myocardial infarction on mortality after percutaneous coronary intervention and coronary artery bypass grafting for leftmain disease: an analysis from the EXCEL trial.

Reference: Ori Ben-Yehuda et al. European Heart Journal (2019) 0, 1–12.

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