The Evaluation of XIENCE versus EXCEL (Coronary Artery Bypass Surgery for Effectiveness
of Left Main Revascularization) trial is the largest randomized study comparing percutaneous
coronary intervention (PCI) with second-generation drug-eluting stents and bypass
surgery in unprotected left main disease (ULMD). Our aim was to assess which proportion
of patients from a contemporary all-comer population of ULMD PCI would be eligible
for the EXCEL trial and whether these patients show different long-term outcomes than
the rest of the ULMD population.
A total of 246 consecutive patients underwent ULMD PCI between January 2018 and December
2021 and were retrospectively analyzed. After application of the EXCEL trial inclusion
and exclusion criteria, 98 patients (39%) were allocated to the “EXCEL-like” cohort
and 148 to the “non-EXCEL-like.” Baseline characteristics of the 2 groups were substantially
comparable. The mean baseline SYNTAX score was lower in the EXCEL-like patients than
the non-EXCEL-like group (20.1 ± 7.1 vs 23.0 ± 11.2, p = 0.025), with the latter also
showing a higher degree of incomplete revascularization (residual SYNTAX score >8 : 11%
vs 26%, p = 0.005). At 1 year, the cumulative major adverse cardiovascular and cerebral
events rate was 7% for the EXCEL-like and 17% for the non-EXCEL-like patients, respectively
(p = 0.03). At the last follow-up available, the significant difference in major adverse
cardiovascular and cerebral events rate persisted (19% vs 37%, p = 0.02) and a significant
difference in any unplanned revascularization was also shown (1.5% vs 13%, p = 0.04).
In conclusion, in a contemporary real-world cohort of ULMD PCI, only a minority of
patients could be enrolled in the EXCEL trial; the EXCEL-like patients, in our population,
showed less clinical events at long-term follow-up than the cohort of patients who
were ineligible for EXCEL, despite comparable baseline cardiovascular profiles; these
findings may challenge a broad external applicability of the results of the EXCEL
trial in routine clinical activity.
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Article info
Publication history
Published online: February 17, 2023
Received in revised form:
December 26,
2022
Received:
November 21,
2022
Publication stage
In Press Journal Pre-ProofFootnotes
Funding: none.
Identification
Copyright
© 2023 Elsevier Inc. All rights reserved.
