Regardless of whether it is attempted through percutaneous coronary intervention (PCI) or myocardial revascularization surgery (MRS), complete revascularization (CR) is not always achieved. Overall, it is more frequent with surgery than with percutaneous treatment.
Additionally, incomplete revascularization (IR) has proven to be associated with worse outcomes compared to CR.
Researchers conducted an analysis of the EXCEL Study comparing CR with IR.
To define the quality of revascularization, they used the residual Jeopardy Score (rJS), considering ≤2 as CR and ≥4 as IR.
Overall, 902 patients were analyzed. Among them, 860 had an rJS ≤2 and 42 had an rJS ≥4.
The primary endpoint at 5 years was a composite of all-cause death and myocardial infarction.
Mean patient age was 66 years, and there were more men in the rJS ≥4 group. There were no significant differences regarding hypertension, smoking, diabetes, prior myocardial infarction, and clinical presentation, but the ejection fraction and prior PCI rates were higher in those with rJS ≥4.
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There were no differences in left main coronary artery (LMCA) lesions and in one- or two-vessel lesions, but the incidence of three-vessel lesions was higher in the rJS ≥4 group. Low SYNTAX scores were higher in those with rJS ≤2, and so was the number of lesions in the ostium and body of the left main coronary artery (LMCA), while high SYNTAX scores were higher in those with rJS ≥4, with more >50% ostial circumflex lesions.
The 5-year primary endpoint favored those with rJS ≤2 (19.5% vs. 38.9% [adjusted hazard ratio (HR), 2.29; 95% confidence interval (CI), 1.11–4.71]; P=0.02). Untreated ostial or proximal circumflex lesions were associated with increased mortality or myocardial infarction at 5 years.
Conclusion
In patients undergoing PCI in the EXCEL Study, incomplete revascularization according to rJS was associated with increased death or myocardial infarction rates. This finding was influenced by the presence of high-grade lesions in the ostium or proximal segment of the circumflex artery.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Original Title: Impact of Incomplete Revascularization After PCI in Left Main Disease: The EXCEL Trial.
Reference: Ziad A. Ali, et al. Circ Cardiovasc Interv. 2024;17:e013192. DOI: 10.1161/CIRCINTERVENTIONS.123.013192.
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