早期手术干预或无症状二尖瓣反流的密切观察等待治疗：系统评价和荟萃分析。
Early surgical intervention or watchful waiting for the management of asymptomatic mitral regurgitation: a systematic review and meta-analysis.
机构信息
1 Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, USA ; 2 Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA ; 3 Department of Health Research and Policy, Stanford University School of Medicine, Stanford, USA.
出版信息
Ann Cardiothorac Surg. 2015 May;4(3):220-9. doi: 10.3978/j.issn.2225-319X.2015.04.01.
BACKGROUND
Discordance between studies drives continued debate regarding the best management of asymptomatic severe mitral regurgitation (MR). The aim of the present study was to conduct a systematic review and meta-analysis of management plans for asymptomatic severe MR, and compare the effectiveness of a strategy of early surgery to watchful waiting.
METHODS
A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies were excluded if they: (I) lacked a watchful waiting cohort; (II) included symptomatic patients; or (III) included etiologies other than degenerative mitral valve disease. The primary outcome of the study was all-cause mortality at 10 years. Secondary outcomes included operative mortality, repair rate, repeat mitral valve surgery, and development of new atrial fibrillation.
RESULTS
Five observational studies were eligible for review and three were included in the pooled analysis. In asymptomatic patients without class I triggers (symptoms or ventricular dysfunction), pooled analysis revealed a significant reduction in long-term mortality with an early surgery approach [hazard ratio (HR) =0.38; 95% confidence interval (CI): 0.21-0.71]. This survival benefit persisted in a sub-group analysis limited to patients without class II triggers (atrial fibrillation or pulmonary hypertension) [relative risk (RR) =0.85; 95% CI: 0.75-0.98]. Aggregate rates of operative mortality did not differ between treatment arms (0.7% vs. 0.7% for early surgery vs. watchful waiting). However, significantly higher repair rates were achieved in the early surgery cohorts (RR =1.10; 95% CI: 1.02-1.18).
CONCLUSIONS
Despite disagreement between individual studies, the present meta-analysis demonstrates that a strategy of early surgery may improve survival and increase the likelihood of mitral valve repair compared with watchful waiting. Early surgery may also benefit patients when instituted prior to the development of class II triggers.
背景
不同研究之间的差异导致针对无症状严重二尖瓣反流（MR）最佳治疗方法的持续争论。本研究的目的是对无症状严重 MR 的治疗方案进行系统回顾和荟萃分析，并比较早期手术与密切观察等待策略的效果。
方法
按照系统评价和荟萃分析的首选报告项目（PRISMA）指南进行系统评价。如果研究符合以下条件，则将其排除：（I）缺乏密切观察等待队列；（II）纳入有症状的患者；或（III）纳入退行性二尖瓣疾病以外的病因。本研究的主要结局为 10 年全因死亡率。次要结局包括手术死亡率、修复率、再次二尖瓣手术和新发心房颤动的发生。
结果
有 5 项观察性研究符合纳入标准，其中 3 项研究纳入荟萃分析。在无症状且无 I 类触发因素（症状或心室功能障碍）的患者中，荟萃分析显示早期手术方法可显著降低长期死亡率[风险比（HR）=0.38；95%置信区间（CI）：0.21-0.71]。这一生存获益在仅限于无 II 类触发因素（心房颤动或肺动脉高压）的亚组分析中仍然存在[相对风险（RR）=0.85；95% CI：0.75-0.98]。治疗组之间的手术死亡率无差异（早期手术组为 0.7%，密切观察等待组为 0.7%）。然而，早期手术组的修复率显著升高（RR=1.10；95% CI：1.02-1.18）。
结论
尽管各研究之间存在分歧，但本荟萃分析表明，与密切观察等待相比，早期手术策略可能提高生存率并增加二尖瓣修复的可能性。早期手术在出现 II 类触发因素之前实施时，也可能使患者受益。
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