Does an occluded RCA affect prognosis in patients undergoing PCI or CABG for left main coronary artery disease?
Shmuel Chen1, Dimitrios Karmpaliotis, Björn Redfors
1Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA.
Insights
In patients with left main coronary artery disease (LMCAD), an occluded right coronary artery (RCA) did not worsen outcomes after revascularization. Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) showed similar results regardless of RCA occlusion.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Left main coronary artery disease (LMCAD) poses significant risks for patients requiring revascularization.
- The impact of concomitant right coronary artery (RCA) occlusion on treatment outcomes in LMCAD is not well-defined.
- The EXCEL trial provides a unique opportunity to investigate this specific clinical scenario.
Purpose of the Study:
- To evaluate the influence of an occluded RCA on the outcomes of patients with LMCAD.
- To compare the efficacy of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in LMCAD patients with and without RCA occlusion.
- To assess the three-year prognosis associated with different revascularization strategies in this patient subgroup.
Main Methods:
- Analysis of data from the EXCEL trial, which randomized 1,905 patients with LMCAD and low-to-intermediate SYNTAX scores (≤32) to PCI or CABG.
- Patients were stratified based on the presence or absence of RCA occlusion at baseline.
- Outcomes were analyzed using multivariable Cox proportional hazards regression, with the primary endpoint being a composite of death, stroke, or myocardial infarction at three years.
Main Results:
- Among 1,753 patients with a dominant RCA, 7.4% had an occluded RCA at baseline.
- Percutaneous coronary intervention (PCI) was attempted in 52.3% of patients with occluded RCA and successfully recanalized 41.5% of these arteries.
- Coronary artery bypass grafting (CABG) was performed in 64.6% of patients with occluded RCA.
- The three-year rates of the primary endpoint were similar between PCI and CABG, irrespective of RCA occlusion status (p-interaction=0.92).
Conclusions:
- The presence of an occluded RCA at baseline does not negatively impact the three-year prognosis for patients with LMCAD undergoing revascularization.
- The choice between PCI and CABG for LMCAD treatment yields similar outcomes, even in the presence of RCA occlusion.
- These findings support current revascularization strategies for LMCAD patients, including those with concomitant RCA occlusion.
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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