Busu Tatiana, Alqahtani Fahad, Badhwar Vinay, Cook Chris C, Rihal Charanjit S, Alkhouli Mohamad
Division of Cardiology, West Virginia School of Medicine, Morgantown, West Virginia.
Department of Cardiothoracic Surgery, West Virginia School of Medicine, Morgantown, West Virginia.
Am J Cardiol. 2018 Jul 15;122(2):302-309. doi: 10.1016/j.amjcard.2018.03.360. Epub 2018 Apr 20.
Percutaneous paravalvular leak (PVL) closure has emerged as a feasible alternative to redo valve surgery. However, comparative data on percutaneous and surgical treatment of PVL are scarce. We performed a systematic review and a meta-analysis of studies on percutaneous and surgical treatments of PVL. Of the 2,267 studies screened, 22 eligible studies were analyzed. Primary end points were technical success, 30-day mortality, stroke, and length of stay. Secondary end points were 1-year mortality, readmission for heart failure, reoperation, and symptomatic improvement at follow-up. A total of 2,373 patients were included, of whom 1,511 (63.7%) underwent percutaneous closure. Technical success was higher with surgery (96.7% vs 72.1%, odds ratio [OR] 9.7, p <0.001) but at the cost of higher 30-day mortality (8.6% vs 6.8%, OR 1.90, p <0.001), a trend toward higher stroke (3.3% vs 1.4%, OR 1.94, p = 0.069), and longer hospitalizations. However, surgery was associated with similar 1-year mortality (17.3% vs 17.2%, OR 1.07, p = 0.67), reoperation (9.1% vs 9.9%, OR 0.72, p = 0.1), readmission for heart failure (13.3% vs 26.4%, OR 0.51, p = 0.29), and improvement in New York Heart Association classification (67.4% vs 56%, OR 1.37, p = 0.74), compared with percutaneous closure. A sensitivity analysis including comparative studies only yielded similar results. Surgical treatment of PVL achieves higher technical success rates but is associated with higher early morbidity and mortality compared with percutaneous closure. Nevertheless, mortality rates and clinical efficacy parameters were similar at midterm with both procedures. Further studies are warranted to identify the ideal management approach to patients with symptomatic PVL.
经皮瓣周漏（PVL）封堵术已成为再次瓣膜手术的一种可行替代方案。然而，关于PVL经皮治疗和手术治疗的比较数据很少。我们对PVL经皮治疗和手术治疗的研究进行了系统评价和荟萃分析。在筛选的2267项研究中，分析了22项符合条件的研究。主要终点为技术成功率、30天死亡率、中风和住院时间。次要终点为1年死亡率、因心力衰竭再次入院、再次手术以及随访时症状改善情况。共纳入2373例患者，其中1511例（63.7%）接受了经皮封堵术。手术的技术成功率更高（96.7%对72.1%，优势比[OR]9.7，p＜0.001），但代价是30天死亡率更高（8.6%对6.8%，OR 1.90，p＜0.001），中风发生率有升高趋势（3.3%对1.4%，OR 1.94，p = 0.069），住院时间更长。然而，与经皮封堵术相比，手术的1年死亡率（17.3%对17.2%，OR 1.07，p = 0.67）、再次手术率（9.1%对9.9%，OR 0.72，p =0.1）、因心力衰竭再次入院率（13.3%对26.4%，OR 0.51，p = 0.29）以及纽约心脏协会分级改善情况（67.4%对56%，OR 1.37，p = 0.74）相似。仅纳入比较研究的敏感性分析得出了类似结果。与经皮封堵术相比，PVL的手术治疗技术成功率更高，但早期发病率和死亡率也更高。尽管如此，两种手术中期的死亡率和临床疗效参数相似。有必要进行进一步研究以确定有症状PVL患者的理想治疗方法。
