Catheterization and Cardiovascular Interventions 77:944 (2011)
Editorial Comment
To Excel Or To Confirm? That is
the Question
George Dangas,* MD, FSCAI
Mount Sinai Medical Center, New York, New York
Following decades a scarce clinical data on left main
revascularization results, there is a recent influx of
data from various geographic areas, also reflected well
in the present paper of Capodanno et al. [1]. These
investigators adopted an innovative approach in their
own center study of left main revascularization. Based
on previous knowledge, severe triple vessel disease
with a high angiographic score has done very well
with bypass surgery, but lower levels of complexity in
multivessel disease and certainly isolated left main dis-
ease have performed very well with percutaneous
approach.
Therefore, patients with left main and multivessel
disease of intermediate or low complexity can be a
very well characterized population for a clinical
research comparison between bypass surgery and
drug-eluting stent implantation. All patients should be
considered good candidates for dual antiplatelet ther-
apy long-term to be deemed appropriate for multives-
sel stenting. The findings of this study [1] are that
mortality and also the combination of death, myocar-
dial infarction or stroke did not differ significantly
between the two revascularization methods, but the
stent approach required more repeat procedures during
follow-up.
' 2011 Wiley-Liss, Inc.
This is a very familiar result, as have seen the exact
same picture in many (in fact, all) earlier studies, analy-
ses or substudies, even including a very recently reported
one from Korea [2]. However, an adequately powered
(large) randomized trial has not been executed prospec-
tively yet. In fact, Capodanno et al., characterize their
study as a prelude to this upcoming randomized trial.
Meanwhile, one should note that practice guidelines have
already been revised, to a certain degree or another, glob-
ally. Questions still remain about which stent and which
drug and for how long one has to keep treating patients
with, but I do not see any groundbreaking comparisons
being conducted to enlighten clinical decision making
regarding therapeutic strategies.
Therefore, my question is exactly what are we
anticipating to learn from this very extensive upcoming
left main disease trial? Obviously not much that we do
not already know. After a number of trials conducted
in different parts of the world by different investigators
have concurred on the main set of results, one can
only expect some ‘‘touches’’ around the edges from an
extensive and expensive ongoing trial. In other words,
we will mostly excel in confirmatory statements!
REFERENCES
1. Capodanno D, Caggegi A, Capranzano P, et al. Validating the
EXCEL hypothesis: a propensity score matched three-year compar-
ison of percutaneous coronary intervention versus coronary artery
bypass graft in left main patients with SYNTAX score  32 Cathe-
ter Cardiovasc Interv 2011;DOI 10.1002/ccd.22992.
2. Park SJ, Kim YH, Park DW, et al. Randomized trial of stents
versus bypass surgery for left main coronary artery disease. N
Engl J Med. 2011;364:1718–1727.
Conflict of interest: Nothing to report.
*Correspondence to: George Dangas, MD, FSCAI, Cardiovascular
Institute (box 1030), Mount Sinai Medical Center, New York, NY
10029. E-mail: George.Dangas@MountSinai.ORG
Received 12 April 2011; Revision accepted 13 April 2011
DOI 10.1002/ccd.23206
Published online 18 May 2011 in Wiley Online Library
(wileyonlinelibrary.com).