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Published on: April 17, 2021
Impact of left ventricular ejection fraction on clinical outcomes after left main coronary artery revascularization:
Daniel J F M Thuijs1, Milan Milojevic1, Gregg W Stone2,3
1Department of Cardiothoracic Surgery, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands.
Insights
Left ventricular ejection fraction (LVEF) impacts 3-year outcomes in left main coronary artery disease (LMCAD) patients. Reduced LVEF, particularly heart failure with reduced ejection fraction (HFrEF), is linked to higher mortality after PCI or CABG.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Left main coronary artery disease (LMCAD) poses significant risks.
- Treatment decisions for LMCAD involve percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).
- The impact of left ventricular ejection fraction (LVEF) on outcomes after LMCAD revascularization requires further elucidation.
Purpose of the Study:
- To assess the influence of baseline LVEF on 3-year clinical outcomes in LMCAD patients treated with PCI or CABG within the EXCEL trial.
- To compare outcomes across different LVEF categories: heart failure with reduced ejection fraction (HFrEF), heart failure with mid-range ejection fraction (HFmrEF), and heart failure with preserved ejection fraction (HFpEF).
Main Methods:
- Analysis of data from the EXCEL trial, which randomized LMCAD patients to PCI or CABG.
- Stratification of patients based on baseline LVEF: <40% (HFrEF), 40-49% (HFmrEF), and ≥50% (HFpEF).
- Evaluation of the composite primary endpoint (death, stroke, myocardial infarction) and all-cause mortality at 3 years.
Main Results:
- Patients with HFrEF experienced longer postoperative hospital stays after CABG compared to those with HFmrEF or HFpEF.
- The 3-year composite endpoint rates were similar between PCI and CABG across all LVEF groups.
- A higher 3-year risk of all-cause death was observed with decreasing LVEF, irrespective of the revascularization strategy (PCI or CABG).
Conclusions:
- In LMCAD patients from the EXCEL trial, reduced LVEF, especially HFrEF, is associated with increased 3-year all-cause mortality.
- No significant differences in the composite endpoint of death, stroke, or myocardial infarction were found between PCI and CABG across LVEF categories.
- Longer-term follow-up is warranted to identify potential emerging differences in clinical outcomes.
Aim:
To evaluate the impact of left ventricular ejection fraction (LVEF) on 3-year outcomes in patients with left main coronary artery disease (LMCAD) undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in the EXCEL trial.
Methods And Results:
The EXCEL trial randomized patients with LMCAD to PCI with everolimus-eluting stents (n = 948) or CABG (n = 957). Among 1804 patients with known baseline LVEF, 74 (4.1%) had LVEF <40% [heart failure with reduced ejection fraction (HFrEF)], 152 (8.4%) LVEF 40-49% [heart failure with mid-range ejection fraction (HFmrEF)] and 1578 (87.5%) LVEF ≥50% (heart failure with preserved ejection fraction). Patients with HFrEF vs. HFmrEF vs. preserved LVEF experienced a longer postoperative hospital stay (9.0 vs. 7.0 vs. 6.0 days, P = 0.02) with greater peri-procedural complications after CABG, while hospital stay after PCI was unaffected by LVEF (1.5 vs. 2.0 vs. 1.0 days, P = 0.20). The composite primary endpoint of death, stroke, or myocardial infarction at 3 years was 29.3% (PCI) vs. 27.6% (CABG) in patients with HFrEF, 16.2% vs. 15.0% in patients with HFmrEF, and 14.5% vs. 14.6% in those with preserved LVEF, respectively (Pinteraction = 0.90). Smoothing spline analysis demonstrated that the 3-year risk of all-cause death increased when LVEF decreased, both in patients undergoing CABG and PCI.
Conclusion:
In the EXCEL trial, the composite rate of death, stroke or myocardial infarction at 3 years was significantly higher in patients with HFrEF compared with HFmrEF or preserved LVEF, driven by an increased rate of all-cause death. No significant differences after PCI vs. CABG were observed among patients with HFrEF, HFmrEF and preserved LVEF. Longer-term follow-up could provide important insights on differences in clinical outcomes that might emerge over time.
Clinical Trial Registration:
ClinicalTrials.gov Identifier NCT01205776.
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