FEATURE CARDIOLOGY


called EXCEL: the definitive unprotected left main randomized trial. The EXCEL trial, which is led in


part by Dr. Joseph Sabik, surgical co- principal investigator of the trial and chairman of Thoracic and Cardiovascular Surgery at Cleveland Clinic’s Sydell and Arnold Miller Heart & Vascular Institute, will include 2,500 consenting patients with simple and intermediate anatomic complexity. The patients will be randomly assigned to undergo surgery or stenting. This large trial follows two moderate-sized trials that began to validate Cleveland Clinic’s work in carefully selecting patients with left main blockages who would perform well with percutaneous coronary intervention rather than surgery. “Up until about three years ago,


treatment of left main blockages was largely considered in the domain of open heart surgery because it had been shown in previous randomized trials to be better than medical therapy, and because of hazards posed with angioplasty and stenting if anything went wrong,” Dr. Ellis says, noting that the risk is greater because of the complexity of left main blockages and because so much heart muscle is at stake. Still, clinical trials are proving that


interventional therapy can as good or better for some patients with significant blockages. One of the first was SYNTAX, which randomized patients with left main disease between surgery and angioplasty with stenting. SYNTAX included about 800 patients, and left main disease was one of the two components of the study. “The study was largely a draw,” Dr. Ellis says of the clinical outcomes of patients who had surgery vs. those with angioplasty and stenting. “It suggested that stenting was reasonably safe.” Patients involved in SYNTAX were


followed for three years, for death, heart attack, stroke and need for further revascularization. Those patients involved also had relatively simple and complex anatomy. “It turns out that those with complex anatomy did better with the surgery whereas patients with more simple and intermediate anatomy tended to perform well with stenting,” Dr. Ellis shares. Another randomized trial called PRECOMBAT – performed in Asia after the Syntax trial – confirmed those findings. Meanwhile, further investigations


have suggested that the anatomic score of simple, intermediate and complex blockages – guidelines set by the American College of Cardiology and American Heart Association for patient management – don’t tell the whole story of whether a patient is a candidate for surgery or angioplasty/stenting. In fact, new guidelines that will be released later this year likely will suggest that patients with a grading of 2A are candidates for stenting, compared to the current 2B classification. Regardless, Dr. Ellis says, “Sophisticated


clinicians and surgeons will make decisions based on that anatomic complexity and the array of clinical findings that are generally encompassed by the EURO score.” Surgery is still the gold standard for


many patients suffering from left main disease. But physicians should have a measured discussion with patients and families about interventional alternatives, Dr. Ellis says. “Stenting must be done in the right context and with the right form of patient consent,” he says. As with other interventional therapies,


patients with left main blockages who receive angioplasty and stenting experience faster recovery times, shorter hospital stays and can return to daily activities sooner. “When you look at medicine as a whole,


there has been a trend toward less invasive procedures and you see that across a whole breadth of surgery,” Dr. Ellis says. “This is an example of the less invasive procedure becoming safer and safer. At Cleveland Clinic, we have been at or near the forefront of exploring this treatment option and it’s nice to see it validated in a large trial.” ■


AH LEARN MORE


The Middle East Interventional Cardiovascular Conference is taking place during Arab Health on 26th January 2012. This one-day event will focus on providing an educational platform to underline the updates and improvements in the field of vascular medicine through presentation of medicial cases in interventional cardiovascular procedures. To find out more and to register you place as a delegate, visit www.arabhealthonline.com


Arab Health Issue 5 2011 77


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