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

Abstract

Aims The prognostic implications of periprocedural myocardial infarction (PMI) after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) remain controversial. We examined the 3-year rates of mortality among patients with and without PMI undergoing left main coronary artery intervention randomized to PCI with everolimus-eluting stents vs. CABG in the large-scale, multicentre, prospective, randomized EXCEL trial. Methods and results By protocol, PMI was defined using an identical threshold for PCI and CABG [creatinine kinase-MB (CK-MB) elevation >10× the upper reference limit (URL) within 72 h post-procedure, or >5× URL with new Q-waves, angiographic vessel occlusion, or loss of myocardium on imaging]. Cox proportional hazards modelling was performed controlling for age, sex, hypertension, diabetes mellitus, left ventricular ejection fraction, SYNTAX score, and chronic obstructive pulmonary disease (COPD). A total of 1858 patients were treated as assigned by randomization. Periprocedural MI occurred in 34/935 (3.6%) of patients in the PCI group and 56/923 (6.1%) of patients in the CABG group [odds ratio 0.61, 95% confidence interval (CI) 0.40–0.93; P = 0.02]. Periprocedural MI was associated with SYNTAX score, COPD, cross-clamp duration and total procedure duration, and not using antegrade cardioplegia. By multivariable analysis, PMI was associated with cardiovascular death and all-cause death at 3 years [adjusted hazard ratio (HR) 2.63, 95% CI 1.19–5.81; P = 0.02 and adjusted HR 2.28, 95% CI 1.22–4.29; P = 0.01, respectively]. The effect of PMI was consistent for PCI and CABG for cardiovascular death (P interaction = 0.56) and all-cause death (P interaction = 0.59). Peak post-procedure CK-MB ≥10× URL strongly predicted mortality, whereas lesser degrees of myonecrosis were not associated with prognosis. Conclusion In the EXCEL trial, PMI was more common after CABG than PCI, and was strongly associated with increased 3-year mortality after controlling for potential confounders. Only extensive myonecrosis (CK-MB ≥10× URL) was prognostically important.

The legacy of ISCHEMIA

“…A similar controversy recently animated the presentation of the 5-year outcomes of the EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial [16]. Finally, the adoption of a definition of periprocedural MI for both PCI and CABG based on CK rise > 10-fold the ULN or > 5-fold the ULN with new Q-waves, angiographic vessel occlusion, or loss of myocardium on imaging was strongly associated with increased 3-year mortality even after controlling for potential confounders [17].…”

Determinants of Periprocedural Myocardial Infarction in Current Elective Percutaneous Coronary Interventions

“…1,[3][4][5] However, complications such as periprocedural myocardial infarction (PMI) still exist. 6,7) Although the incidence of PMI widely varied among 2% 30%, which depended on the definitions of PMI, PMI was associated with future cardiovascular events, including cardiac death. [7][8][9][10][11] Earlier studies reported the relationship between PMI and clinical factors such as lesion/stent length, bifurcation lesions, SYNTAX score, and left main disease.…”

“…6,7) Although the incidence of PMI widely varied among 2% 30%, which depended on the definitions of PMI, PMI was associated with future cardiovascular events, including cardiac death. [7][8][9][10][11] Earlier studies reported the relationship between PMI and clinical factors such as lesion/stent length, bifurcation lesions, SYNTAX score, and left main disease. 7,9,12,13) However, the factors associated with PMI in contemporary elective PCI were not fully understood.…”

Perioperative myocardial infarction during coronary artery bypass grafting. The main approaches to diagnosis and prevention

“…По данным литературы, у 32-44% пациентов после КШ наблюдается повреждение миокарда [5,6]. Важно отметить, что частота диагностируемых ИМ в послеоперационном периоде КШ зависит от критериев диагностики и характеристик анализируемой когорты пациентов и составляет от 0 до 30% [7][8][9]. Так, в работе Cho MS, et al (2017) продемонстрировано, что частота развития периоперационного ИМ в одной выборке варьирует от 1,9% до 18,3% при использовании различных диагностических критериев [10].…”

“…Результаты многоцентрового проспективного рандомизированного исследования EXCEL, включившего пациентов с поражением ствола левой коронарной артерии и низким или промежуточным числом баллов по шкале SYNTAX, демонстрируют, что перипроцедурный ИМ при выполнении КШ ассоциировался с тяжестью поражения коронарных артерий, оцененной до операции по шкале SYNTAX, наличием сопутствующей хронической обструктивной болезнью легких (ХОБЛ), длительностью интраоперационного пережатия аорты. При этом частота его развития составила 6,1% [8]. Наличие сопутствующих заболеваний является важным фактором, потенцирующим периоперационное повреждение миокарда.…”