Yokoyama Yujiro, Takagi Hisato, Kuno Toshiki
Department of Surgery, St. Luke's University Health Network, Bethlehem, Pa.
Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan.
J Thorac Cardiovasc Surg. 2022 May;163(5):1778-1785.e5. doi: 10.1016/j.jtcvs.2020.06.078. Epub 2020 Jul 5.
Although current guidelines generally recommend watchful waiting strategy for patients with asymptomatic severe aortic stenosis until symptoms develop, early surgery for asymptomatic aortic stenosis remains controversial. This study aimed to compare the outcomes of early surgery versus conservative strategy for patients with asymptomatic severe aortic stenosis.
MEDLINE and EMBASE were searched through February 2020 to identify clinical trials that investigated early surgery and conservative strategy for patients with asymptomatic severe aortic stenosis. From each study, we extracted the hazard ratio of all-cause mortality and cardiovascular mortality. Subgroup analyses were conducted by dividing into severe aortic stenosis (peak aortic jet velocity ≥4.0 m/s, mean aortic pressure gradient ≥40 mm Hg, or aortic valve area ≤1.0 cm) and very severe aortic stenosis (peak aortic jet velocity ≥4.5 m/s, mean pressure gradient ≥50 mm Hg, or aortic valve area ≤0.75 cm) groups.
One randomized controlled trial and 7 observational studies were identified. Pooled analyses demonstrated that all-cause mortality and cardiovascular mortality for early surgery were significantly lower compared with conservative strategy (hazard ratio, 0.49; 95% confidence interval, 0.36-0.68; P < .0001, hazard ratio, 0.42; 95% confidence interval, 0.22-0.82; P = .01, respectively). Subgroup analyses showed significant reduction for early surgery in all-cause mortality (severe aortic stenosis: hazard ratio, 0.52; 95% confidence interval, 0.35-0.78; P = .001, very severe aortic stenosis: hazard ratio, 0.38; 95% confidence interval, 0.17-0.85; P = .02).
We demonstrated that early surgery was associated with significant reduction in all-cause and cardiovascular mortality in patients with severe aortic stenosis. Further randomized trials are warranted to confirm our findings.
尽管当前指南通常建议对无症状重度主动脉瓣狭窄患者采取观察等待策略，直至出现症状，但无症状主动脉瓣狭窄的早期手术治疗仍存在争议。本研究旨在比较无症状重度主动脉瓣狭窄患者早期手术与保守策略的治疗结果。
检索MEDLINE和EMBASE至2020年2月，以确定研究无症状重度主动脉瓣狭窄患者早期手术和保守策略的临床试验。从每项研究中，我们提取了全因死亡率和心血管死亡率的风险比。通过分为重度主动脉瓣狭窄（主动脉峰值流速≥4.0米/秒、平均主动脉压力阶差≥40毫米汞柱或主动脉瓣面积≤1.0平方厘米）和极重度主动脉瓣狭窄（主动脉峰值流速≥4.5米/秒、平均压力阶差≥50毫米汞柱或主动脉瓣面积≤0.75平方厘米）组进行亚组分析。
确定了1项随机对照试验和7项观察性研究。汇总分析表明，与保守策略相比，早期手术的全因死亡率和心血管死亡率显著更低（风险比分别为0.49；95%置信区间为0.36 - 0.68；P <.0001，风险比为0.42；95%置信区间为0.22 - 0.82；P = 0.01）。亚组分析显示，早期手术在全因死亡率方面有显著降低（重度主动脉瓣狭窄：风险比为0.52；95%置信区间为0.35 - 0.78；P = 0.001，极重度主动脉瓣狭窄：风险比为0.38；95%置信区间为0.17 - 0.85；P = 0.02）。
我们证明早期手术与重度主动脉瓣狭窄患者的全因死亡率和心血管死亡率显著降低相关。需要进一步的随机试验来证实我们的发现。
