Kotronias Rafail A, Kwok Chun Shing, George Sudhakar, Capodanno Davide, Ludman Peter F, Townend Jonathan N, Doshi Sagar N, Khogali Saib S, Généreux Philippe, Herrmann Howard C, Mamas Mamas A, Bagur Rodrigo
Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, United Kingdom.
Oxford University Clinical Academic Graduate School, Oxford University, Oxford, United Kingdom.
J Am Heart Assoc. 2017 Jun 27;6(6):e005960. doi: 10.1161/JAHA.117.005960.
Recent recommendations suggest that in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation and coexistent significant coronary artery disease, the latter should be treated before the index procedure; however, the evidence basis for such an approach remains limited. We performed a systematic review and meta-analysis to study the clinical outcomes of patients with coronary artery disease who did or did not undergo revascularization prior to transcatheter aortic valve implantation.
We conducted a search of Medline and Embase to identify studies evaluating patients who underwent transcatheter aortic valve implantation with or without percutaneous coronary intervention. Random-effects meta-analyses with the inverse variance method were used to estimate the rate and risk of adverse outcomes. Nine studies involving 3858 participants were included in the meta-analysis. Patients who underwent revascularization with percutaneous coronary intervention had a higher rate of major vascular complications (odd ratio [OR]: 1.86; 95% confidence interval [CI], 1.33-2.60; =0.0003) and higher 30-day mortality (OR: 1.42; 95% CI, 1.08-1.87; =0.01). There were no differences in effect estimates for 30-day cardiovascular mortality (OR: 1.03; 95% CI, 0.35-2.99), myocardial infarction (OR: 0.86; 95% CI, 0.14-5.28), acute kidney injury (OR: 0.89; 95% CI, 0.42-1.88), stroke (OR: 1.07; 95% CI, 0.38-2.97), or 1-year mortality (OR: 1.05; 95% CI, 0.71-1.56). The timing of percutaneous coronary intervention (same setting versus a priori) did not negatively influence outcomes.
Our analysis suggests that revascularization before transcatheter aortic valve implantation confers no clinical advantage with respect to several patient-important clinical outcomes and may be associated with an increased risk of major vascular complications and 30-day mortality. In the absence of definitive evidence, careful evaluation of patients on an individual basis is of paramount importance to identify patients who might benefit from elective revascularization.
近期建议指出，对于接受经导管主动脉瓣植入术且并存严重冠状动脉疾病的患者，应在进行该指数手术前治疗后者；然而，这种方法的证据基础仍然有限。我们进行了一项系统评价和荟萃分析，以研究在经导管主动脉瓣植入术前接受或未接受血运重建的冠状动脉疾病患者的临床结局。
我们检索了Medline和Embase，以确定评估接受或未接受经皮冠状动脉介入治疗的经导管主动脉瓣植入术患者的研究。采用逆方差法进行随机效应荟萃分析，以估计不良结局的发生率和风险。荟萃分析纳入了9项涉及3858名参与者的研究。接受经皮冠状动脉介入血运重建的患者发生主要血管并发症的发生率较高（比值比[OR]：1.86；95%置信区间[CI]，1.33 - 2.60；P = 0.0003），30天死亡率也较高（OR：1.42；95% CI，1.08 - 1.87；P = 0.01）。30天心血管死亡率（OR：1.03；95% CI，0.35 - 2.99）、心肌梗死（OR：0.86；95% CI，0.14 - 5.28）、急性肾损伤（OR：0.89；95% CI，0.42 - 1.88）、中风（OR：1.07；95% CI，0.38 - 2.97）或1年死亡率（OR：1.05；95% CI，0.71 - 1.56）的效应估计值无差异。经皮冠状动脉介入治疗的时机（同一机构与先于手术）对结局没有负面影响。
我们的分析表明，在经导管主动脉瓣植入术前进行血运重建在几个对患者重要的临床结局方面没有临床优势，并且可能与主要血管并发症风险增加和30天死亡率升高相关。在缺乏确凿证据的情况下，对患者进行个体化的仔细评估对于识别可能从择期血运重建中获益的患者至关重要。
