Cheng Davy C H, Martin Janet, Lal Avtar, Diegeler Anno, Folliguet Thierry A, Nifong L Wiley, Perier Patrick, Raanani Ehud, Smith J Michael, Seeburger Joerg, Falk Volkmar
Department of Anesthesia & Perioperative Medicine, Evidence-Based Perioperative Clinical Outcomes Research Group (EPiCOR), London Health Sciences Centre, University of Western Ontario, London, ON, Canada.
Innovations (Phila). 2011 Mar;6(2):84-103. doi: 10.1097/IMI.0b013e3182167feb.
: This meta-analysis sought to determine whether minimally invasive mitral valve surgery (mini-MVS) improves clinical outcomes and resource utilization compared with conventional open mitral valve surgery (conv-MVS) in patients undergoing mitral valve repair or replacement.
: A comprehensive search of MEDLINE, Cochrane Library, EMBASE, CTSnet, and databases of abstracts was undertaken to identify all randomized and nonrandomized studies up to March 2010 of mini-MVS through thoracotomy versus conv-MVS through median sternotomy for mitral valve repair or replacement. Outcomes of interest included death, stroke, myocardial infarction, aortic dissection, need for reintervention, and any other reported clinically relevant outcomes or indicator of resource utilization. Relative risk and weighted mean differences and their 95% confidence intervals were analyzed as appropriate using the random effects model. Heterogeneity was measured using the I statistic.
: Thirty-five studies met the inclusion criteria (two randomized controlled trials and 33 nonrandomized studies). The mortality rate after mini-MVS versus conv-MVS was similar at 30 days (1.2% vs 1.5%), 1 year (0.9% vs 1.3%), 3 years (0.5% vs 0.5%), and 9 years (0% vs 3.7%). A number of clinical outcomes were significantly improved with mini-MVS versus conv-MVS including atrial fibrillation (18% vs 22%), chest tube drainage (578 vs 871 mL), transfusions, sternal infection (0.04% vs 0.27%), time to return to normal activity, and patient scar satisfaction. However, the 30-day risk of stroke (2.1% vs 1.2%), aortic dissection/injury (0.2% vs 0%), groin infection (2% vs 0%), and phrenic nerve palsy (3% vs 0%) were significantly increased for mini-MVS versus conv-MVS. Other clinical outcomes were similar between groups. Cross-clamp time, cardiopulmonary bypass time, and procedure time were significantly increased with mini-MVS; however, ventilation time and length of stay in intensive care unit and hospital were reduced.
: Current evidence suggests that mini-MVS maybe associated with decreased bleeding, blood product transfusion, atrial fibrillation, sternal wound infection, scar dissatisfaction, ventilation time, intensive care unit stay, hospital length of stay, and reduced time to return to normal activity, without detected adverse impact on long-term need for valvular reintervention and survival beyond 1 year. However, these potential benefits for mini-MVS may come with an increased risk of stroke, aortic dissection or aortic injury, phrenic nerve palsy, groin infections/complications, and increased cross-clamp, cardiopulmonary bypass, and procedure time. Available evidence is largely limited to retrospective comparisons of small cohorts comparing mini-MVS versus conv-MVS that provide only short-term outcomes. Given these limitations, randomized controlled trials with adequate power and duration of follow-up to measure clinically relevant outcomes are recommended to determine the balance of benefits and risks.
本荟萃分析旨在确定在接受二尖瓣修复或置换的患者中，与传统开放性二尖瓣手术（conv-MVS）相比，微创二尖瓣手术（mini-MVS）是否能改善临床结局并提高资源利用效率。
全面检索MEDLINE、Cochrane图书馆、EMBASE、CTSnet以及摘要数据库，以识别截至2010年3月的所有关于经胸廓切开术的mini-MVS与经正中胸骨切开术的conv-MVS进行二尖瓣修复或置换的随机和非随机研究。感兴趣的结局包括死亡、中风、心肌梗死、主动脉夹层、再次干预的必要性以及任何其他报告的临床相关结局或资源利用指标。使用随机效应模型酌情分析相对风险和加权平均差及其95%置信区间。使用I统计量测量异质性。
35项研究符合纳入标准（2项随机对照试验和33项非随机研究）。mini-MVS与conv-MVS术后30天（1.2%对1.5%）、1年（0.9%对1.3%）、3年（0.5%对0.5%）和9年（0%对3.7%）的死亡率相似。与conv-MVS相比，mini-MVS显著改善了一些临床结局，包括房颤（18%对22%）、胸管引流量（578对871毫升）、输血、胸骨感染（0.04%对0.27%）、恢复正常活动的时间以及患者对瘢痕的满意度。然而，mini-MVS与conv-MVS相比，30天时中风风险（2.1%对1.2%）、主动脉夹层/损伤（0.2%对0%）、腹股沟感染（2%对0%）和膈神经麻痹（3%对0%）显著增加。两组之间的其他临床结局相似。mini-MVS的主动脉阻断时间、体外循环时间和手术时间显著增加；然而，通气时间以及在重症监护病房和医院的住院时间缩短。
目前的证据表明，mini-MVS可能与出血减少、血制品输注减少、房颤、胸骨伤口感染、瘢痕不满意、通气时间、重症监护病房住院时间、医院住院时间减少以及恢复正常活动的时间缩短相关，且未发现对瓣膜再次干预的长期需求和1年以上生存率有不利影响。然而，mini-MVS的这些潜在益处可能伴随着中风、主动脉夹层或主动脉损伤、膈神经麻痹、腹股沟感染/并发症风险增加，以及主动脉阻断、体外循环和手术时间增加。现有证据在很大程度上仅限于对比较mini-MVS与conv-MVS的小队列进行的回顾性比较，且仅提供短期结局。鉴于这些局限性，建议进行具有足够样本量和随访时间以测量临床相关结局的随机对照试验，以确定益处和风险的平衡。
