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Impact of Periprocedural Adverse Events After PCI and CABG on 5-Year Mortality: The EXCEL Trial
Sneha S Jain1, Ditian Li2, Ovidiu Dressler2
1Division of Cardiovascular Medicine, Stanford University, Palo Alto, California, USA.
Insights
Major adverse events (MAE) after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) significantly increase mortality risk. These risks persist long-term, highlighting the importance of monitoring complications post-revascularization for left main coronary artery disease.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- The comparative impact of periprocedural major adverse events (MAE) on long-term mortality following left main coronary artery revascularization via percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) remains underexplored.
- Existing research has not fully elucidated the differential risks associated with various MAEs after PCI and CABG concerning subsequent patient survival.
Purpose of the Study:
- To evaluate the association between periprocedural MAEs occurring within 30 days of PCI or CABG and both early and late mortality.
- To analyze the impact of specific nonfatal MAEs on 5-year all-cause and cardiovascular mortality in patients undergoing left main coronary artery revascularization.
Main Methods:
- Utilized data from the EXCEL trial, randomizing 1,858 patients with left main disease to either PCI or CABG.
- Employed logistic regression to examine the associations between 12 prespecified nonfatal MAEs and subsequent 5-year all-cause and cardiovascular death.
- Assessed mortality outcomes within the first 30 days and between 30 days and 5 years postprocedure.
Main Results:
- A higher incidence of MAEs was observed in the CABG group (45.4%) compared to the PCI group (11.9%) (P < 0.0001).
- Experiencing any MAE independently predicted a significantly higher risk of 5-year mortality after both PCI (adjusted OR: 4.61) and CABG (adjusted OR: 3.25).
- Major or minor bleeding requiring significant transfusion, stroke, unplanned revascularization, and renal failure were identified as specific predictors of mortality, with some events being procedure-specific.
Conclusions:
- Nonfatal periprocedural MAEs are strongly linked to both early and late mortality following left main coronary artery revascularization, irrespective of the procedure (PCI or CABG).
- The occurrence of MAEs, including bleeding, stroke, unplanned revascularization, and renal failure, significantly impacts long-term survival in patients treated for left main coronary artery disease.
Background:
The relative risks for different periprocedural major adverse events (MAE) after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) on subsequent mortality have not been described.
Objectives:
The aim of this study was to assess the association between periprocedural MAE occurring within 30 days postprocedure and early and late mortality after left main coronary artery revascularization by PCI and CABG.
Methods:
In the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, patients with left main disease were randomized to PCI vs CABG. The associations between 12 prespecified nonfatal MAE and subsequent 5-year all-cause and cardiovascular death in 1,858 patients were examined using logistic regression.
Results:
One or more nonfatal MAE occurred in 111 of 935 patients (11.9%) after PCI and 419 of 923 patients (45.4%) after CABG (P < 0.0001). Patients with MAE were older and had more baseline comorbidities. Within 5 years, all-cause death occurred in 117 and 87 patients after PCI and CABG, respectively. Experiencing an MAE was a strong independent predictor of 5-year mortality after both PCI (adjusted OR: 4.61; 95% CI: 2.71-7.82) and CABG (adjusted OR: 3.25; 95% CI: 1.95-5.41). These associations were present within the first 30 days and between 30 days and 5 years postprocedure. Major or minor bleeding with blood transfusion ≥2 U was an independent predictor of 5-year mortality after both procedures. Stroke, unplanned revascularization for ischemia, and renal failure were significantly associated with mortality only after CABG.
Conclusions:
In the EXCEL trial, nonfatal periprocedural MAE were strongly associated with early and late mortality after both PCI and CABG for left main disease.
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