Iwanski Jessika, Knapp Shannon M, Avery Ryan, Oliva Isabel, Wong Raymond K, Runyan Raymond B, Khalpey Zain
Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, USA.
BIO5 Institute, Statistics Consulting Lab, University of Arizona, Tucson, AZ, USA.
J Cardiothorac Surg. 2017 May 19;12(1):37. doi: 10.1186/s13019-017-0602-8.
Randomized and nonrandomized clinical trials have tried to assess whether or not TMR patients experience an increase in myocardial perfusion. However there have been inconsistencies reported in the literature due to the use of different nuclear imaging modalities to test this metric. The primary purpose of this meta-analysis was to determine whether SPECT, MUGA and PET scans demonstrate changes in myocardial perfusion between lased and non-lased subjects and whether laser type affects myocardial perfusion. The secondary purpose was to examine the overall effect of laser therapy on clinical outcomes including survival, hospital re-admission and angina reduction.
Sixteen studies were included in the primary endpoint analysis after excluding all other non-imaging TMR papers. Standardized mean difference was used as the effect size for all quantitative outcomes and log odds ratio was used as the effect size for all binary outcomes.
Statistically significant improvements in myocardial perfusion were observed between control and treatment groups in myocardial perfusion at 6-month follow up using PET imaging with a porcine model. However non-significant differences were observed in patients at 3 and 12 months using SPECT, PET or MUGA scans. Both CO and Ho:YAG laser systems demonstrated an increase in myocardial perfusion however this effect was not statistically significant. In addition both laser types displayed statistically significant decreases in patient angina at 3, 6 and 12 months but non-significant increases in survival rates and decreases in hospital re-admissions.
In order to properly assess myocardial perfusion in TMR subjects, subendocardial perfusion needs to be analyzed via nuclear imaging. PET scans can provide this level of sensitivity and should be utilized in future studies to monitor and detect perfusion changes in lased and non-lased subjects.
随机和非随机临床试验试图评估经皮心肌激光打孔（TMR）患者的心肌灌注是否增加。然而，由于使用不同的核成像方式来测试这一指标，文献中报道的结果并不一致。本荟萃分析的主要目的是确定单光子发射计算机断层扫描（SPECT）、多门电路心血池显像（MUGA）和正电子发射断层扫描（PET）扫描是否能显示激光治疗组和未治疗组之间的心肌灌注变化，以及激光类型是否影响心肌灌注。次要目的是研究激光治疗对临床结局的总体影响，包括生存率、住院再入院率和心绞痛减轻情况。
在排除所有其他非成像TMR论文后，16项研究被纳入主要终点分析。标准化均数差用作所有定量结局的效应量，对数比值比用作所有二元结局的效应量。
在猪模型中，使用PET成像在6个月随访时观察到对照组和治疗组之间心肌灌注有统计学显著改善。然而，在3个月和12个月时，使用SPECT、PET或MUGA扫描的患者中未观察到显著差异。二氧化碳（CO）和钬（Ho:YAG）激光系统均显示心肌灌注增加，但这种效应无统计学显著性。此外，两种激光类型在3个月、6个月和12个月时患者心绞痛均有统计学显著降低，但生存率无显著增加，住院再入院率无显著降低。
为了正确评估TMR患者的心肌灌注，需要通过核成像分析心内膜下灌注。PET扫描可以提供这种灵敏度水平，应在未来研究中用于监测和检测激光治疗组和未治疗组的灌注变化。
