Chi Kuan-Yu, Chiang Ming-Hsiu, Kang Yi-No, Li Shao-Jung, Chan Yueh-Tsung, Chen Yang-Ching, Wang Sen-Te
Department of Education, Center for Evidence-Based Medicine, Taipei Medical University Hospital, Taipei, Taiwan.
School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
J Thorac Cardiovasc Surg. 2022 Jun;163(6):2057-2071.e12. doi: 10.1016/j.jtcvs.2020.05.101. Epub 2020 Jul 5.
The optimal selection of prosthetic heart valve for dialysis-dependent patients remains controversial. We investigated the comparative effectiveness and safety of mechanical prosthesis (MP) and bioprosthesis (BP) for these patients.
After the systematic review, we included studies that involved patients on dialysis undergoing aortic valve replacement or mitral valve replacement (MVR) and reported comparative outcomes of MP and BP. Meta-analysis was performed using random-effects model. We conducted a subgroup analysis based on the valve position and postoperative international normalized ratio (INR), which was extracted from either tables or methods of each study. A meta-regression was used to examine the effects of study-level covariates.
We included 24 retrospective studies without randomized-controlled trials, involving 10,164 participants (MP = 6934, BP = 3230). Patients undergoing aortic valve replacement with MP exhibited a better long-term survival effectiveness (hazard ratio, 0.64; 95% confidence interval [CI], 0.47-0.86). Conversely, studies including MVR demonstrated little difference in survival (hazard ratio, 0.90; 95% CI, 0.73-1.12). A meta-regression revealed that age had little effect on long-term survival difference between MP and BP (β = -0.0135, P = .433). MP had a significantly greater bleeding risk than did BP when INR was above 2.5 (incidence rate ratio, 10.58; 95% CI, 2.02-55.41). However, when INR was below 2.5, bleeding events were comparable (incidence rate ratio, 1.73; 95% CI, 0.78-3.82). The structural valve deterioration rate was significantly lower in MP (risk ratio, 0.24; 95% CI, 0.14-0.44).
MP is a reasonable choice for dialysis-dependent patients without additional thromboembolic risk requiring aortic valve replacement, for its better long-term survival, durability, and noninferior bleeding risk compared with BP. Conversely, BP might be an appropriate selection for patients with MVR, given its similar survival rate and lower bleeding risk. Although our meta-regression demonstrates little influence of age on long-term survival difference between MP and BP, further studies stratifying patients based on age cut-off are mandatory.
对于依赖透析的患者，人工心脏瓣膜的最佳选择仍存在争议。我们调查了机械瓣膜（MP）和生物瓣膜（BP）用于这些患者的相对有效性和安全性。
在系统评价之后，我们纳入了涉及接受主动脉瓣置换术或二尖瓣置换术（MVR）的透析患者并报告了MP和BP比较结果的研究。使用随机效应模型进行荟萃分析。我们根据瓣膜位置和术后国际标准化比值（INR）进行亚组分析，INR从每项研究的表格或方法中提取。使用荟萃回归来检验研究水平协变量的影响。
我们纳入了24项回顾性研究，没有随机对照试验，涉及10164名参与者（MP = 6934，BP = 3230）。接受MP主动脉瓣置换术的患者表现出更好的长期生存有效性（风险比，0.64；95%置信区间[CI]，0.47 - 0.86）。相反，包括MVR的研究在生存方面差异不大（风险比，0.90；95%CI，0.73 - 1.12）。荟萃回归显示年龄对MP和BP之间的长期生存差异影响不大（β = -0.0135，P = 0.433）。当INR高于2.5时，MP的出血风险显著高于BP（发病率比值，10.58；95%CI，2.02 - 55.41）。然而，当INR低于2.5时，出血事件相当（发病率比值，1.73；95%CI，0.78 - 3.82）。MP的结构性瓣膜退化率显著更低（风险比，0.24；95%CI，0.14 - 0.44）。
对于依赖透析且无额外血栓栓塞风险需要进行主动脉瓣置换的患者，MP是一个合理选择，因为与BP相比，它具有更好的长期生存、耐用性和非劣性出血风险。相反，对于MVR患者，BP可能是合适的选择，因为其生存率相似且出血风险更低。尽管我们的荟萃回归显示年龄对MP和BP之间的长期生存差异影响不大，但仍需进一步根据年龄界限对患者进行分层研究。
