Wang Zhenhua, Zhou Chenghui, Gu Haiyong, Zheng Zhe, Hu Shengshou
Department of Surgery, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
J Heart Valve Dis. 2013 May;22(3):333-9.
Rheumatic fever is still the main cause of valve disease in developing countries. The study aim was to investigate the appropriateness of mitral valve repair in adult patients with rheumatic heart disease (RHD).
A systematic literature retrieval was performed for all clinical trials comparing the outcomes of mitral valve repair and replacement for RHD in PubMed, EMBASE and the Cochrane Library. Studies were excluded if they lacked a direct comparison of repair versus replacement. The primary outcomes were 30-day and long-term (> 5 years) survival. Secondary outcomes were postoperative complications and reoperation rates. Standard meta-analysis techniques were used.
A total of seven studies was included. When comparing mitral valve repair (MVP) to mitral valve replacement (MVR), the summary odds ratio for 30-day mortality was 0.54 (95% confidence interval (CI) 0.34-0.86; p = 0.009), and the summary hazard ratio (HR) for long-term mortality was 0.62 (95% CI 0.45-0.85; p = 0.003). Other than the benefits of better survival rates, the risk of postoperative complications (cardiac death, bleeding or thromboembolic complications) was also lower in the repair group (HR 0.63; 95% CI 0.47-0.84; p = 0.002). A significantly higher reoperation rate was observed among patients with mitral valve repair (HR 1.85; 95% CI 1.41-2.43; p < 0.01).
Mitral valve repair provides better short-term and long-term event-free survival for rheumatic patients. With an acceptable reoperation rate, MVP is also more beneficial by avoiding troublesome lifelong anticoagulation. Thus, whenever possible, MVP should be attempted in patients with RHD.
在发展中国家，风湿热仍是瓣膜病的主要病因。本研究旨在探讨成年风湿性心脏病（RHD）患者二尖瓣修复术的适宜性。
在PubMed、EMBASE和Cochrane图书馆中对所有比较RHD二尖瓣修复术和置换术结果的临床试验进行系统文献检索。若研究缺乏修复与置换的直接比较，则予以排除。主要结局为30天和长期（>5年）生存率。次要结局为术后并发症和再次手术率。采用标准的荟萃分析技术。
共纳入7项研究。比较二尖瓣修复术（MVP）和二尖瓣置换术（MVR）时，30天死亡率的汇总比值比为0.54（95%置信区间（CI）0.34 - 0.86；p = 0.009），长期死亡率的汇总风险比（HR）为0.62（95%CI 0.45 - 0.85；p = 0.003）。除了生存率更高的益处外，修复组术后并发症（心脏死亡、出血或血栓栓塞并发症）的风险也更低（HR 0.63；95%CI 0.47 - 0.84；p = 0.002）。二尖瓣修复术患者的再次手术率显著更高（HR 1.85；95%CI 1.41 - 2.43；p < 0.01）。
二尖瓣修复术为风湿性患者提供了更好的短期和长期无事件生存率。由于再次手术率可接受，MVP还因避免了麻烦的终身抗凝而更具益处。因此，对于RHD患者，应尽可能尝试MVP。
