The EXCEL Trial: The Surgeons’ Perspective

Q: What is the clinical evidence from this study?

Study design: Review. Population: Left main stem disease (n=1905). Intervention: Percutaneous coronary intervention (PCI) with everolimus-eluting stent vs. Coronary artery bypass graft (CABG) surgery. Primary outcome: Composite of death, stroke or MI (p=0.13).

Marjan Jahangiri; Krishna Priya Mani; Martin T. Yates; Justin Nowell

doi:10.15420/ecr.2020.34

November 9, 2020European Cardiology ReviewOpen Access

The EXCEL Trial: The Surgeons’ Perspective

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Why the study?

The EXCEL trial comparing PCI and CABG for left main stem disease has garnered significant controversy regarding its experimental design and reporting of results.

Does percutaneous coronary intervention compared to coronary artery bypass grafting improve outcomes in patients with left main stem disease?

Structured PICO

Does percutaneous coronary intervention compared to coronary artery bypass grafting improve outcomes in patients with left main stem disease?

P

Population

Patients with left main stem (LMS) disease

I

Intervention

Percutaneous coronary intervention (PCI)

C

Comparator

Coronary artery bypass grafting (CABG)

O

Outcome

Composite of death, stroke, or myocardial infarction (and MACCE)composite

Main Result

Absolute Event Rate: 22% vs 19.2%

p-value: p=0.13

This review outlines methodological concerns with the EXCEL trial and argues that CABG remains the superior treatment for the vast majority of patients with left main stem disease.

Limitations

Use of the SCAI definition of peri-procedural MI rather than the Universal Definition of MI
All-cause mortality was classified as a secondary endpoint despite being significantly higher in the PCI group
Repeat revascularization was excluded from the primary endpoint
The CABG group was heterogeneous with low use of multiple arterial grafting
Small number of eligible patients in RCTs
Atypical patient populations
Short duration of follow-up
Large number of crossovers
Methodological controversies in EXCEL including MI definition and secondary endpoint reporting

Implication

Does not support shifting from CABG to PCI in left main disease; leaves open questions on EXCEL methodology and long-term outcomes.

Abstract

There have been several investigations comparing the efficacy of percutaneous coronary intervention and coronary artery bypass grafting surgery for treatment of left main stem disease. This includes the Evaluation of XIENCE versus Coronary Artery Bypass Graft Surgery for Effectiveness of Left Main Revascularizaton (EXCEL) trial, which has garnered significant controversy surrounding its experimental design and reporting of its results. The authors review the methodology, results, caveats and statements on the EXCEL trial. They also review the other trials in the management of left main stem disease comparing percutaneous coronary intervention with coronary artery bypass grafting, as well as the SYNTAX score and its role in future guidelines for revascularisation. These findings have significant implications for current practice, influencing the growing role for multidisciplinary team meeting and allowing clinicians and patients to make the right choice.

Discussion

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Cite This Study

Jahangiri et al. (2020) conducted a review in Left main stem disease (n=1,905). Percutaneous coronary intervention (PCI) with everolimus-eluting stent vs. Coronary artery bypass graft (CABG) surgery was evaluated on Composite of death, stroke or MI (p=0.13).

synapsesocial.com/papers/6a1c992e973ffece4bc40938 https://doi.org/10.15420/ecr.2020.34

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The EXCEL Trial: The Surgeons’ Perspective

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

The EXCEL Trial: The Surgeons’ Perspective

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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