Sanfilippo Filippo, Johnson Christopher, Bellavia Diego, Morsolini Marco, Romano Giuseppe, Santonocito Cristina, Centineo Luigi, Pastore Federico, Pilato Michele, Arcadipane Antonio
Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy.
Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA.
J Cardiothorac Vasc Anesth. 2017 Oct;31(5):1681-1691. doi: 10.1053/j.jvca.2017.02.046. Epub 2017 Feb 13.
To assess differences in mitral regurgitation (MR) grade between the preoperative and the intraoperative evaluations.
Systematic review and meta-analysis of 6 observational studies found from MEDLINE and EMBASE.
Cardiac surgery.
One hundred thirty-seven patients.
Comparison between the preoperative MR assessment and the intraoperative evaluation conducted under general anesthesia (GA), with or without "hemodynamic matching" (HM) (artificial increase of afterload).
The primary outcome was the difference between the preoperative and intraoperative MR grade under "GA-only" or "after-HM." Secondary analyses addressed differences according to effective regurgitant orifice area (EROA), regurgitant volume (RVol), color-jet area, and vena contracta width. Risk of MR underestimation was found under "GA-only" (SMD: 0.55; 95% confidence interval [CI], 0.31-0.79, p < 0.00001), but not "after-HM" (SMD: -0.16; 95% CI, -0.46 to 0.13, p = 0.27). Under "GA-only", EROA had a trend toward underestimation (p = 0.07), RVol was reliable (p = 0.17), while reliance on color-jet area and vena contracta width incur risk of underestimation (both p = 0.003). After HM, EROA accurately reflected preoperative MR (p = 0.68) while RVol had a trend toward overestimation (p = 0.05). The overall reported incidence of misdiagnoses was slightly more common under "GA-only" (mean 48%, 39% underestimation, 9% overestimation; range: 32%-57%) than "after-HM" (mean 41%, 12% underestimation, 29% overestimation; range: 33%-50%). Only the minority of misdiagnoses were clinically relevant: underestimation was around 10% (both approaches), but 18% had clinically significant overestimation "after-HM" as compared with 3% under GA-only.
Intraoperative assessment under "GA-only" significantly underestimated MR. A more accurate intraoperative evaluation can be obtained with afterload manipulation, although HM strategy carries high risk of clinically significant overestimation.
评估二尖瓣反流（MR）分级在术前和术中评估之间的差异。
对从MEDLINE和EMBASE检索到的6项观察性研究进行系统评价和荟萃分析。
心脏外科手术。
137例患者。
比较术前MR评估与全身麻醉（GA）下进行的术中评估，术中评估有无“血流动力学匹配”（HM）（人为增加后负荷）。
主要结局是“单纯GA”或“HM后”时术前和术中MR分级的差异。次要分析探讨了根据有效反流口面积（EROA）、反流容积（RVol）、彩色血流喷射面积和反流束缩流宽度的差异。发现在“单纯GA”时存在MR低估风险（标准化均数差：0.55；95%置信区间[CI]，0.31 - 0.79，p < 0.00001），但在“HM后”不存在（标准化均数差： - 0.16；95%CI， - 0.46至0.13，p = 0.27）。在“单纯GA”时，EROA有低估趋势（p = 0.07），RVol可靠（p = 0.17），而依赖彩色血流喷射面积和反流束缩流宽度存在低估风险（p均 = 0.003）。HM后，EROA准确反映术前MR（p = 0.68），而RVol有高估趋势（p = 0.05）。总体报告的误诊发生率在“单纯GA”时（平均48%，39%低估，9%高估；范围：32% - 57%）比“HM后”（平均41%，12%低估，29%高估；范围：33% - 50%）略高。只有少数误诊具有临床相关性：低估约为10%（两种方法），但“HM后”有18%的高估具有临床意义，而“单纯GA”时为3%。
“单纯GA”下的术中评估显著低估了MR。通过后负荷操作可获得更准确的术中评估，尽管HM策略存在临床显著高估的高风险。
