BACKGROUND The SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score (SS), a measure of anatomic coronary artery disease (CAD) extent and complexity, has proven useful in past studies to determine the absolute and relative prognosis after revascularization with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). We sought to assess contemporary outcomes after PCI and CABG in patients with left main CAD according to SS and revascularization type from a large randomized trial. METHODS The EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) randomized patients with left main CAD and site-assessed SS≤32 to PCI with everolimus-eluting stents or CABG. Four-year outcomes were examined according to angiographic core laboratory-assessed SS using multivariable Cox proportional hazards regression. RESULTS A total of 1840 patients with left main CAD randomized to PCI (n=914) versus CABG (n=926) had angiographic core laboratory SS assessment. The mean SS was 26.5±9.3 (range 5-74); 24.1% of patients had angiographic core laboratory-assessed SS ≥33. The 4-year rate of the primary major adverse cardiac event end point of death, stroke, or myocardial infarction was similar between PCI and CABG (18.6% versus 16.7%, respectively; P=0.40) and did not vary according to SS (Pinteraction=0.33). Rates of ischemia-driven revascularization rose with increasing SS after PCI, but not after CABG. As a result, the major secondary composite end point of major adverse cardiac or cerebrovascular events (major adverse cardiac event or ischemia-driven revascularization) occurred more frequently with PCI than CABG (28.0% versus 22.0%, P=0.01), a difference which rose progressively with increasing SS (Pinteraction=0.03). CONCLUSIONS In the EXCEL trial, the 4-year primary composite major adverse cardiac event end point of death, myocardial infarction, or stroke was similar after PCI with everolimus-eluting stents and CABG and was independent of the baseline anatomic complexity and extent of CAD. In contrast, the relative and absolute hazard of major adverse cardiac or cerebrovascular events with PCI compared with CABG rose progressively with the SS. These data should be considered by the heart team when deciding between PCI versus CABG for revascularization in patients with left main CAD. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier NCT01205776.

中文翻译：

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根据SYNTAX评分，左主干冠状动脉疾病血运重建。

背景技术SYNTAX（红豆杉经皮冠状动脉介入治疗与心脏外科手术之间的协同作用）评分（SS）是解剖性冠状动脉疾病（CAD）程度和复杂程度的一种衡量标准，在过去的研究中证实了其有效性，可用于确定通过冠状动脉搭桥术进行血管重建后的绝对和相对预后经皮冠状动脉介入治疗（PCI）与冠状动脉搭桥术（CABG）的比较。我们试图通过一项大型随机试验根据SS和血运重建类型评估左主干CAD患者PCI和CABG后的当代预后。方法EXCEL试验（XIENCE与冠状动脉搭桥术对左主血运重建术效果的评估）将左主CAD和SS≤32的位点评估SS≤32的患者随机分为依维莫司洗脱支架或CABG。根据血管造影核心实验室评估的SS，使用多变量Cox比例风险回归对四年结局进行了检查。结果共有1840例患者的左主CAD随机分为PCI（n = 914）和CABG（n = 926），接受了血管造影核心实验室SS评估。平均SS为26.5±9.3（范围5-74）; 24.1％的患者血管造影核心实验室评估的SS≥33。PCI和CABG的主要主要不良心脏事件终点死亡，中风或心肌梗塞的4年发生率相似（分别为18.6％和16.7％； P = 0.40），并且与SS无关（交互作用） = 0.33）。PCI后，缺血驱动的血运重建率随SS增加而增加，但CABG后则不增加。因此，与CABG相比，PCI发生的主要不良心脏或脑血管事件（主要不良心脏事件或缺血性血运重建）的主要次要复合终点发生率更高（28.0％对22.0％，P = 0.01），且随着增加而逐渐增加SS（互动= 0.03）。结论在EXCEL试验中，使用依维莫司洗脱支架和CABG进行PCI后，为期4年的主要主要主要不良心脏事件的死亡，心肌梗塞或中风终点相似，并且独立于基线解剖学复杂性和CAD程度。相比之下，与CABG相比，PCI的主要不良心脏或脑血管事件的相对危险和绝对危险随SS逐渐增加。在决定左主CAD患者的PCI与CABG之间进行血运重建时，心脏小组应考虑这些数据。临床试验注册网址：https：//www.clinicaltrials.gov。唯一标识符NCT01205776。