Department of Cardiology, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.
Eur Heart J. 2013 Jun;34(21):1557-66. doi: 10.1093/eurheartj/ehs486. Epub 2013 Jan 17.
Left-sided prosthetic valve thrombosis (PVT) occurs frequently in developing countries and causes major morbidity and mortality. Fibrinolytic therapy (FT) is most commonly used as treatment, but increases the risk of stroke and bleeding. Urgent surgery may be more efficacious and cause fewer complications. Our aim was to compare the efficacy and safety of urgent surgery and FT for the treatment of left-sided PVT.
We searched EMBASE and MEDLINE for articles which included at least five patients each treated with surgery and FT. The primary outcome was complete restoration of valve function. Other outcomes were in-hospital death, thrombo-embolism (stroke, transient ischaemic attack, or non-CNS systemic embolism), major bleeding, and recurrence of PVT on follow-up. We calculated odds ratios (ORs) for each outcome and pooled them using a random effects model. We included seven eligible studies with 690 episodes of PVT, 446 treated with surgery, and 244 with FT. There was no significant difference in the occurrence of the primary outcome (86.5 vs. 69.7%, OR 2.53, 95% CI 0.94-6.78, P = 0.066, I(2) = 74%) or death (13.5 vs. 9%, OR 1.95, 95% CI 0.63-5.98, P = 0.244, I(2) = 59%) between the two treatments. However, compared with FT, urgent surgery was associated with significant reductions in thrombo-embolism (1.6 vs. 16%, OR 0.10, 95% CI 0.04-0.24, P < 0.001, I(2) = 0%), major bleeding (1.4 vs. 5%; OR 0.27, 95% CI 0.08-0.98, P = 0.046, I(2) = 0%), and recurrent PVT (7.1 vs. 25.4%; OR 0.25, 95% CI 0.08-0.74, P = 0.013, I(2) = 59%).
Urgent surgery was not superior to FT at restoring valve function, but substantially reduced the occurrence of thrombo-embolic events, major bleeding, and recurrent PVT. In experienced centres, urgent surgery should probably be preferred over FT for treating left-sided PVT, pending the results of randomized controlled trials.
左心人工瓣膜血栓形成（PVT）在发展中国家较为常见，可导致严重的发病率和死亡率。纤溶治疗（FT）是最常用的治疗方法，但会增加中风和出血的风险。紧急手术可能更有效且引起的并发症更少。我们的目的是比较紧急手术和 FT 治疗左心 PVT 的疗效和安全性。
我们在 EMBASE 和 MEDLINE 上搜索了至少各有 5 例患者接受手术和 FT 治疗的文章。主要结局是瓣膜功能完全恢复。其他结局包括住院期间死亡、血栓栓塞（中风、短暂性脑缺血发作或非中枢神经系统系统性栓塞）、大出血以及随访期间 PVT 复发。我们计算了每个结局的优势比（OR），并使用随机效应模型对其进行了汇总。我们纳入了 7 项符合条件的研究，共 690 例 PVT 患者，其中 446 例接受手术治疗，244 例接受 FT 治疗。两种治疗方法在主要结局（86.5% vs. 69.7%，OR 2.53，95%CI 0.94-6.78，P = 0.066，I(2) = 74%）或死亡（13.5% vs. 9%，OR 1.95，95%CI 0.63-5.98，P = 0.244，I(2) = 59%）的发生率方面无显著差异。然而，与 FT 相比，紧急手术与血栓栓塞（1.6% vs. 16%，OR 0.10，95%CI 0.04-0.24，P < 0.001，I(2) = 0%）、大出血（1.4% vs. 5%；OR 0.27，95%CI 0.08-0.98，P = 0.046，I(2) = 0%）和 PVT 复发（7.1% vs. 25.4%；OR 0.25，95%CI 0.08-0.74，P = 0.013，I(2) = 59%）的发生率显著降低。
紧急手术在恢复瓣膜功能方面并不优于 FT，但可显著降低血栓栓塞事件、大出血和 PVT 复发的发生率。在经验丰富的中心，对于治疗左心 PVT，紧急手术可能优于 FT，有待随机对照试验的结果。
