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

Eur Heart J. 2019 Jun 21;40(24):1930-1941. doi: 10.1093/eurheartj/ehz113.


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 (Pinteraction = 0.56) and all-cause death (Pinteraction = 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.

Keywords: Coronary artery bypass grafting; Left main coronary artery; Percutaneous coronary intervention; Periprocedural myocardial infarction; Revascularization.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Case-Control Studies
  • Coronary Artery Bypass / adverse effects*
  • Coronary Artery Disease / blood
  • Coronary Artery Disease / diagnostic imaging
  • Coronary Artery Disease / therapy*
  • Creatine Kinase, MB Form / analysis
  • Drug-Eluting Stents / adverse effects
  • Everolimus / therapeutic use
  • Female
  • Humans
  • Male
  • Middle Aged
  • Mortality / trends
  • Myocardial Infarction / epidemiology
  • Myocardial Infarction / etiology*
  • Myocardial Infarction / metabolism
  • Myocardial Infarction / mortality*
  • Percutaneous Coronary Intervention / adverse effects*
  • Perioperative Period / statistics & numerical data
  • Prognosis
  • Prospective Studies
  • Pulmonary Disease, Chronic Obstructive / complications
  • Stroke Volume / physiology
  • Ventricular Function, Left / physiology


  • Everolimus
  • Creatine Kinase, MB Form