Left Main Coronary Disease – Selecting the Best Treatment

Aug 18, 2023

Left Main Coronary Disease – Selecting the Best Treatment

In patients with left main coronary artery disease of low or intermediate anatomical complexity, there was no significant difference between percutaneous coronary intervention and coronary-artery bypass grafting with respect to the rate of the composite outcome of death, stroke, or myocardial infarction at 5 years.

Joining us today to discuss the findings of the EXCEL Trail and how it has impacted clinical treatment is Juan A. Crestanello, M.D., a cardiovascular surgeon and Chair of the Department of Cardiovascular Surgery, and Malcolm R. Bell, M.D., an interventional cardiologist and Vice Chair of Cardiology at Mayo Clinic in Rochester, Minnesota.

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Content

6.399 -> hi my name is kyle clarich and i'm vice

9.2 -> chair for clinical practice in

11.519 -> cardiology consultant cardiology in

13.599 -> rochester minnesota at the mayo clinic

16.16 -> and we are here today for one of our

18.4 -> sessions interview with the experts and

20.64 -> i'm joined by two of my colleagues dr

23.519 -> juan crestanello professor of surgery

26.24 -> and chair of the department of

27.92 -> cardiovascular surgery and malcolm bell

30.96 -> vice chair of cardiology and professor

33.92 -> of medicine and we are going to take on

36.239 -> the topic today of left main coronary

39.04 -> artery disease selecting the best

41.12 -> therapy for your patient

43.04 -> and we're going to start out because of

44.96 -> the new truck of a relatively new trial

46.8 -> the excel trial that

48.96 -> has

49.76 -> raised our awareness and recent

51.44 -> guidelines that were published and maybe

53.6 -> i'll just start out by asking juan what

56 -> was the excel trial can you give us a

57.92 -> little summary of what kind of patients

59.84 -> they studied and what that major

61.68 -> outcomes were

63.28 -> sure

64.159 -> thank you kyle um

66.32 -> so the excel trial was a prospective a

69.439 -> multi-center a randomized trial

72.799 -> that enrolled

74.08 -> around 1900 patients

76.72 -> with left main coronary artery disease

78.799 -> and those patients

80.64 -> were randomized either to pci or a

84.24 -> coronary artery bypass surgery

86.88 -> the primary outcome was a com combined

90.159 -> endpoint of death a stroke of my

92.799 -> myocardial infarction

94.96 -> the trial follow patients to up to five

97.28 -> years

98.64 -> and

99.6 -> at five years

101.119 -> the primary outcome death

103.92 -> stroke or or micro infection was not

106.96 -> different between coronary artery bypass

109.84 -> surgery or percutaneous coronary

112.88 -> intervention great thank you do you

115.04 -> think that um the population of patients

119.04 -> within the exile trial was

121.04 -> representative of what most of us see in

123.119 -> day-to-day practice

125.52 -> well the

126.84 -> um the population was a

131.76 -> as any a clinical trial was

135.36 -> strictly

136.72 -> defined

138.319 -> um the the severity of the coronary

141.04 -> artery disease was a

143.44 -> what we call or the complexity of the

145.44 -> coronary artery disease was low or

147.84 -> intermediate and that was evaluated a

151.28 -> by the syntax core

154.239 -> which was overall a low and that tells

158.4 -> you that the the severity and complexity

160.8 -> of coronary artery disease was a

164.319 -> was was low or or intermediate

167.76 -> and in addition to that there was a a

170.56 -> slow

171.599 -> proportion of a diabetic patients a low

174.48 -> proportion of diabetic patients around

177.12 -> 30 percent

178.48 -> who are

179.68 -> the patients who in general had more

182.64 -> extensive coronary artery disease and

184.56 -> more complex coronary artery disease and

186.56 -> we know

187.92 -> that those patients are the ones that

190.4 -> benefit the most

192.239 -> from from surgical revascularization

196.319 -> in addition there was a the majority of

199.12 -> the patients were were male

201.44 -> and there was a a a a low

204.08 -> proportion of a female patients in the

206.239 -> trial

208.08 -> and was there do you think there was any

209.68 -> differences between the cabbage patients

212.56 -> and the pci patients

215.28 -> or percutaneous intervention patients

219.519 -> well there was some

221.76 -> baselines a

223.519 -> difference but

225.28 -> but one of the differences that can be

228.08 -> impactful in terms of the outcomes was

230.159 -> the difference in the compliance of

231.76 -> medications and the in the follow-up

234 -> period where the the pci

237.12 -> patients were

238.799 -> there was a higher higher a proportion

241.84 -> of patients who were

243.439 -> taking antiplatelets a dual antiplatelet

246 -> agency agents than a compared to the to

248.959 -> the coronary artery bypass surgery

251.2 -> patients

252.56 -> and what was that or was there a time

254.48 -> dependence uh on the outcomes

258.639 -> yeah certainly there was a at a time um

262.88 -> if you look at the overall result of the

264.8 -> trial

265.84 -> the composite endpoint of death stroke

268 -> or rmi there was a

270.4 -> chain initial benefit

272.8 -> for for pci

275.04 -> and about a two and a half to three

277.44 -> years there was a

279.6 -> change in

281.04 -> the in the outcomes where you you could

283.84 -> still see in an increase

286.32 -> um

287.28 -> increased rate of a death a stroke or mi

290.72 -> on the

292.24 -> pci patients compared to

294.8 -> to the cabbages so

296.72 -> after the first two and a half years um

299.759 -> the initial advantage of a pci

303.28 -> a was lost

304.96 -> and that was mostly

306.88 -> related to

308.56 -> the

309.44 -> the increased rate of a micro infarction

312.08 -> and the increased rate of a death after

314.72 -> that two and a half years

316.8 -> that's that's really interesting so

318.32 -> there was an initial interest or initial

320.88 -> benefit to the pci group and then the

322.72 -> curves crossed right in the middle about

324.479 -> two and a half years of the five years

326 -> and then there was the later time frame

328.16 -> there was a benefit for the cabbage

330.24 -> patients based on

332.4 -> myocardial infarction

334.16 -> and death as opposed to stroke so that's

337.12 -> very interesting not the composite

338.72 -> endpoint then

339.919 -> what does the result

341.6 -> then tell us about our clinical practice

343.84 -> how does it impact and maybe i'll ask

346.56 -> both of us both of you to

349.039 -> comment on

350.479 -> what your has this changed your practice

352.72 -> at all the excel trial um how do we how

355.919 -> do we take this into account when we're

357.6 -> thinking about an individual patient in

359.44 -> the office

361.44 -> malcolm maybe i'll let you go first

364.56 -> thanks kyle you know i think that

366.8 -> it's just worth remembering that you

368.56 -> know when you asked about you know

370.639 -> the type of patients in this study

373.199 -> the first thing i think we need to be

375.039 -> aware is is that

378.16 -> about 15 or so were actually acs

381.039 -> patients they'd had an mi in the last uh

383.039 -> your week or so so that's a very small

386.08 -> population but it's a population we see

388 -> a lot obviously in the hospital practice

390.319 -> uh that is 60 had stable ischemic heart

393.12 -> disease so

395.039 -> this is really the group of patients

396.56 -> that you're talking about that

398.4 -> you're discussing the the findings of

401.039 -> their angiogram in the

403.44 -> in the office

405.36 -> but i think that um

408.56 -> it probably hasn't changed our practice

410.639 -> too much for you because obviously we've

412.56 -> been doing by surgery on these patients

414.319 -> for a long time but

416.16 -> we certainly here at mayo and other

417.68 -> places have been doing pci for left main

419.599 -> disease for for many years and and

422 -> remember the the original excel the

424 -> trial publication was back in 2016 so uh

428.319 -> and that's really i think sort of shaped

430.56 -> how we've approached these patients

432.24 -> along with uh you know a couple of other

434.24 -> large left main trials

436.8 -> but i think that

438.16 -> you know it's important to remember that

439.68 -> many patients were excluded from from

441.36 -> that trial and so like any randomized

444.56 -> trial you know it's a selected

446.319 -> population

447.84 -> so

448.96 -> i think the important thing though is

450.639 -> and this is something that hasn't

451.919 -> changed in our practice

454.08 -> except for emergencies we do not do ad

457.36 -> hoc pci in left main disease in stable

460.639 -> patients i think it's important

462.639 -> you know to take them off the table and

464.56 -> and have that discussion uh with them

467.52 -> and then it's just a matter of patient

469.039 -> selection and we can go into more detail

471.12 -> in

471.84 -> in terms of that but uh so as i said i

475.36 -> think it hasn't really changed that

476.8 -> practice here too much we've got two

478.479 -> very effective and safe procedures

480.96 -> but as uh dr castanello pointed out it's

484.56 -> the long-term outcome which is really

486.4 -> important and we did see those curves

488.24 -> start to diverge uh they may diverge

490.56 -> even further in 10 years time you know

492.96 -> with the 10-year follow-up

495.12 -> this was a non-inferiority trial and and

497.599 -> the still was not inferior in five years

499.36 -> but you could see that uh reversal and

501.759 -> separation of those curves

504.08 -> so one thank you malcolm uh juan would

506.639 -> you have anything to add to that has it

508.56 -> changed the way you

510.16 -> practice clinically

512.479 -> not really i mean we um i agree with the

515.839 -> dr bell

517.039 -> we

519.039 -> here at mayo we had a

521.76 -> collaborative approach in terms of a

524.08 -> decision making

525.76 -> where we um

528.24 -> the the heart team has a

532.24 -> discussion about the the the patients

535.6 -> and and a base on

538.72 -> the

540 -> patient overall patient situation

543.04 -> we make a decision what the the best

545.04 -> treatment would be and that

547.2 -> involved considerations in terms of the

549.519 -> complexity of the left main disease

552.72 -> the presence of

554.72 -> additional a coronary artery disease in

557.279 -> in other territories like

559.839 -> the led territory the circumflex and the

562.08 -> right coronary artery

563.839 -> the overall cardiac function the

565.6 -> presence of other

567.36 -> cardiac

569.12 -> pathologies

570.48 -> and

572 -> the

573.04 -> the age of the patients the the

576.399 -> life expectancy and other comorbidities

578.64 -> and the ability to pull the patient

581.12 -> successfully through surgery

583.76 -> as well as the patient's preference

586.56 -> are all factors that we consider in that

589.519 -> type of a decision

591.76 -> so then

593.36 -> i'll pose this question to both of you

595.2 -> too is what are the

597.76 -> patients that you would consider to be

599.76 -> most

600.64 -> benefited from

602 -> coronary artery bypass which left main

604.56 -> patients would you have

606.24 -> a tendency to to recommend coronary

608.48 -> artery bypass grafting versus

611.36 -> a percutaneous coronary intervention

615.279 -> well maybe as i'm not wearing the

616.56 -> surgical hat i think it'd be reasonable

618.56 -> for me to uh

620.079 -> give an honest opinion there because as

622.48 -> dr christina says we do work in concert

624.959 -> together and and we're referring um

628.16 -> each other patients uh and that's been a

630.72 -> you know a long-standing practice here

632.959 -> at mayo

634.079 -> but i think you know when you see a

636.48 -> patient who's got an angiogram that

638.32 -> clearly shows severe left main disease

641.2 -> i i think the patients are best suited

643.12 -> for surgery and the ones that we would

645.12 -> tend to sort of shy away from doing pci

648 -> on would be those who have distal left

650.56 -> main you know this is bifurcation it's

652.56 -> already more complex disease but

654.48 -> particularly if it's associated with

656.32 -> multivessel disease particularly complex

659.2 -> coronary artery disease

661.04 -> and

661.92 -> and also you know

664.32 -> if we can't completely revascularize the

666.24 -> patient i mean that's clearly an

667.68 -> indication for surgery

670 -> and as dr kristen hello said you know

672.72 -> the diabetic patient i mean these are

674.64 -> the patients that we probably should be

676.079 -> doing bypass surgery on

678.48 -> i also think that all things being equal

681.2 -> probably the younger patients we

683.2 -> probably really have to

685.92 -> perhaps have a preference for

687.279 -> recommending

688.399 -> bypass surgery over stenting and one

691.12 -> thing which we haven't discussed is you

692.8 -> know the mortality difference and and

695.04 -> although that was not statistically

696.88 -> significant um

698.8 -> uh

699.92 -> significantly different in the five-year

702.24 -> follow-up uh it did cause some

704.24 -> controversy there's about a three

705.36 -> percent absolute difference and we don't

707.44 -> know what's going to happen uh in the

708.88 -> future and so that younger patient i

712.32 -> think they really need to be appraised

713.839 -> that you know the possible

715.44 -> benefit in terms of needing further

717.68 -> procedures and particularly that there

720.079 -> might be a survival difference

722.72 -> um the older patient though

725.92 -> these are very often the patients who

727.279 -> come along with lots of comorbidities

730.079 -> very often the surgeons are maybe a

732.32 -> little hesitant about you know offering

734.32 -> you know open-heart surgery

736.16 -> and if they have suitable anatomy and we

738.639 -> can you know offer complete or

740.72 -> near-complete revascularization i think

742.88 -> those are the ones that are better for

744.72 -> pci

746 -> uh the easy ones of course are the ones

747.76 -> who have osteo and shaft

749.92 -> uh your disease

751.68 -> um and but again i think this comes down

754.399 -> to a shared decision making with the

756.839 -> patient dr crosstail also mentioned

759.44 -> about patient preference and and

761.839 -> sometimes you

763.44 -> have a patient that you really think

765.12 -> probably is going to benefit from

766.399 -> surgery

767.92 -> but

769.04 -> and you can show them survival curves

771.2 -> and all the data but they're still

773.44 -> reluctant to undergo open heart surgery

775.279 -> it's a small number of patients but i

777.12 -> think we have to make sure we

778.32 -> accommodate their

780.24 -> um your expectations and

782.72 -> and what they would like

784.56 -> to have in terms of revascularization

787.68 -> uh dr christine did i miss out anything

790.24 -> there i mean

791.44 -> does that resonate with you

793.76 -> absolutely i think that i agree with all

796.56 -> those

797.92 -> those same statement uh and the only

800.959 -> thing that i will add

803.12 -> in terms of the of the young patients

805.68 -> and and also on the diabetic patients

808 -> the the benefit the the long-term

810.079 -> benefits of bypass surgery

813.12 -> is enhanced by the use of arterial

816.12 -> revascularization so they add in a

818.8 -> second a memory artery in addition to

821.279 -> the lima to the led

823.04 -> that will

825.839 -> have a additional advantage in terms of

828.56 -> long-term

829.68 -> long-term survival

831.92 -> one of the things that we we learned

833.92 -> from the

835.519 -> from

836.56 -> from from the excel trial and i think

838.48 -> that's important to point out is that

841.76 -> the

842.639 -> mortality

844.56 -> benefit

846.24 -> of a

847.68 -> surgery

849.279 -> a

850.24 -> or the survival benefit of surgery are

852.88 -> are not seen until you know the two and

856.16 -> a half years or so

858 -> that's the that's the statistical when

861.12 -> when when the curve starts to cross and

863.76 -> and diverge so if

866.399 -> and that provides an important piece of

868.48 -> information if we have a patient

870.8 -> who for whatever reason either because

872.959 -> of their age or because of their

874.959 -> comorbidities

877.04 -> their life expectancy is going to be

879.04 -> limited

881.44 -> less than two and a half years

883.44 -> the the the possibility of realizing the

886 -> benefit from a coronary artery bypass

888.399 -> surgery are going to be very limited and

891.12 -> those in those patients

894.399 -> pci

895.76 -> would be

896.72 -> you know beneficial for them better than

899.279 -> surgery

900.48 -> so if i can summarize and please feel

902.639 -> free to correct me if i say anything out

905.199 -> of line here if i'm a non-invasive

907.36 -> non-surgical per colleague here but all

910.24 -> left main

911.6 -> patients are not the same that's what

913.279 -> i'm hearing

914.32 -> and that

915.76 -> since they're not the same we would

917.36 -> probably have a tendency to lean towards

919.92 -> coronary artery bypass grafting in

922.639 -> younger patients with a longer survival

925.6 -> in patients with

927.6 -> complex

929.12 -> coronary artery disease

931.44 -> and maybe those that are

933.36 -> have less comorbidities but also maybe

936.399 -> lean towards it in diabetes even though

938.399 -> that might be a little counter-intuitive

939.92 -> but we've learned that from many years

941.44 -> ago

942.8 -> and then the pci patients maybe uh we

946 -> would tend towards the percutaneous

948.079 -> interventions and those patients that

949.92 -> have less lesion complexity so you know

952.48 -> the syntax score of less than 33

955.6 -> and increased

957.839 -> comorbid

959.199 -> problems and a shorter life span

961.759 -> but in the at the end of the day the

963.92 -> heart team and the discussion between

967.279 -> the patient

968.8 -> the surgeon and the cardiologists

971.6 -> interventionalists are very important

974.639 -> and we have to take into consideration

977.04 -> the patient's expectations and wishes

980.56 -> and one last thing i think was uh was

982.8 -> important to point out is that you you

984.48 -> mentioned the option for arterial grafts

986.88 -> so left internal mammary right internal

989.36 -> manner maybe even both

991.759 -> um in some of these patients and so

993.68 -> that's a consideration to uh to add to

996.32 -> the list even though it wasn't directly

998.56 -> necessarily covered

1000.959 -> in their earlier discussion so this is

1003.12 -> great well it's been great to have this

1005.44 -> conversation and i hope it helps our our

1007.92 -> listeners to better understand how we

1011.519 -> think about these patients with what we

1014.16 -> consider to be a very serious illness

1016 -> that's left main coronary artery disease

1019.199 -> thank you for your attention

1021.12 -> until next time have a great day

Source: https://www.youtube.com/watch?v=Tjx5JadvZ_I