经导管主动脉瓣置换术的直接主动脉途径与经腋动脉途径：一项系统评价和荟萃分析。
Direct aortic route versus transaxillary route for transcatheter aortic valve replacement: a systematic review and meta-analysis.
作者信息
Lee Hsiu-An, Su I-Li, Chen Shao-Wei, Wu Victor Chien-Chia, Chen Dong-Yi, Chu Pao-Hsien, Chou An-Hsun, Cheng Yu-Ting, Lin Pyng-Jing, Tsai Feng-Chun
机构信息
Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan.
Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan.
出版信息
PeerJ. 2020 May 12;8:e9102. doi: 10.7717/peerj.9102. eCollection 2020.
BACKGROUND
The transfemoral route is contraindicated in nearly 10% of transcatheter aortic valve replacement (TAVR) candidates because of unsuitable iliofemoral vessels. Transaxillary (TAx) and direct aortic (DAo) routes are the principal nonfemoral TAVR routes; however, few studies have compared their outcomes.
METHODS
We performed a systematic review and meta-analysis to compare the rates of mortality, stroke, and other adverse events of TAx and DAo TAVR. The study was prospectively registered with PROSPERO (registration number: CRD42017069788). We searched Medline, PubMed, Embase, and Cochrane databases for studies reporting the outcomes of DAo or TAx TAVR in at least 10 patients. Studies that did not use the Valve Academic Research Consortium definitions were excluded. We included studies that did not directly compare the two approaches and then pooled rates of events from the included studies for comparison.
RESULTS
In total, 31 studies were included in the quantitative meta-analysis, with 2,883 and 2,172 patients in the DAo and TAx TAVR groups, respectively. Compared with TAx TAVR, DAo TAVR had a lower Society of Thoracic Surgery (STS) score, shorter fluoroscopic time, and less contrast volume use. The 30-day mortality rates were significantly higher in the DAo TAVR group (9.6%, 95% confidence interval (CI) = [8.4-10.9]) than in the TAx TAVR group (5.7%, 95% CI = [4.8-6.8]; for heterogeneity <0.001). DAo TAVR was associated with a significantly lower risk of stroke in the overall study population (2.6% vs. 5.8%, for heterogeneity <0.001) and in the subgroup of studies with a mean STS score of ≥8 (1.6% vs. 6.2%, for heterogeneity = 0.005). DAo TAVR was also associated with lower risks of permanent pacemaker implantation (12.3% vs. 20.1%, for heterogeneity = 0.009) and valve malposition (2.0% vs. 10.2%, for heterogeneity = 0.023) than was TAx TAVR.
CONCLUSIONS
DAo TAVR increased 30-day mortality rate compared with TAx TAVR; by contrast, TAx TAVR increased postoperative stroke, permanent pacemaker implantation, and valve malposition risks compared with DAo TAVR.
背景
由于髂股血管不合适，近10%的经导管主动脉瓣置换术（TAVR）候选患者禁忌经股动脉途径。经腋动脉（TAx）和直接主动脉（DAo）途径是主要的非股动脉TAVR途径；然而，很少有研究比较它们的结果。
方法
我们进行了一项系统评价和荟萃分析，以比较TAx和DAo TAVR的死亡率、卒中及其他不良事件发生率。该研究已在国际前瞻性系统评价注册库（PROSPERO）前瞻性注册（注册号：CRD42017069788）。我们检索了Medline、PubMed、Embase和Cochrane数据库，查找报告至少10例患者的DAo或TAx TAVR结果的研究。未采用瓣膜学术研究联盟定义的研究被排除。我们纳入了未直接比较这两种方法的研究，然后汇总纳入研究的事件发生率进行比较。
结果
定量荟萃分析共纳入31项研究，DAo和TAx TAVR组分别有2883例和2172例患者。与TAx TAVR相比，DAo TAVR的胸外科医师协会（STS）评分更低，透视时间更短，造影剂用量更少。DAo TAVR组的30天死亡率（9.6%，95%置信区间（CI）=[8.4-10.9]）显著高于TAx TAVR组（5.7%，95%CI=[4.8-6.8]；异质性P<0.001）。在总体研究人群中，DAo TAVR的卒中风险显著更低（2.6%对5.8%，异质性P<0.001），在平均STS评分≥8的研究亚组中也是如此（1.6%对6.2%，异质性P=0.005）。与TAx TAVR相比，DAo TAVR的永久起搏器植入风险（12.3%对20.1%，异质性P=0.009）和瓣膜位置异常风险（2.0%对10.2%，异质性P=0.023）也更低。
结论
与TAx TAVR相比，DAo TAVR增加了30天死亡率；相反，与DAo TAVR相比，TAx TAVR增加了术后卒中、永久起搏器植入和瓣膜位置异常风险。
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