Flynn Campbell D, Williams Michael L, Chakos Adam, Hirst Lucy, Muston Benjamin, Tian David H
Department of Cardiothoracic Surgery, Epworth Hospital, Richmond, Melbourne, Australia.
The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.
Ann Cardiothorac Surg. 2020 Sep;9(5):364-374. doi: 10.21037/acs-2020-surd-27.
The treatment of aortic valve disease is the most common valvular surgery in industrialized nations, with 3-9% of the population over the age of eighty having at least moderate aortic stenosis. As transcatheter aortic valve replacement (TAVR) has become more established, newer surgical prostheses have been developed with a variety of anchoring systems that do not rely solely on sutures to hold the valve in an appropriate position. The Edwards Intuity valve is a bovine pericardial prosthesis that is modelled on the widely implanted Perimount MagnaEase aortic prosthesis. The Perceval valve is a bovine pericardial valve attached to a self-expanding nitinol stent, which uses the radial force exerted on the patient's aortic annulus and aortic root by the stent portion to hold the valve in position. This meta-analysis compares the outcomes of comparative studies of these two valve systems.
This systematic review and meta-analysis compares the outcomes of rapid deployment valves (RDV) and sutureless valves (SURD) and was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations and guidance. The search strategy interrogated six electronic databases. Outcomes measured included all-cause mortality at latest follow up, stroke, cross-clamp and cardiopulmonary bypass (CPB) times, pacemaker implantation rates, paravalvular leak and post-operative transvalvular gradient.
The search strategy identified 407 unique papers for initial assessment with seven studies qualifying for inclusion in the analysis. The outcomes of 4,076 patients (1,650 RDV, 2,426 SURD) were included. There was no difference in mortality, stroke or moderate or worse paravalvular regurgitation between the two groups. SURD had significantly shorter CPB time by 15.7 minutes [95% confidence interval (CI): 4.2-27.1; P=0.007] and a shorter cross-clamp time by 11.3 minutes (95% CI: 6.3-16.3; P<0.001) compared to RDV. RDV had a lower post-operative transvalvular gradient by 2.5 mmHg (95% CI: 1.2-3.8; P<0.001) and a lower rate of mild paravalvular regurgitation (OR 2.51; 95% CI: 1.435-4.768; P=0.004).
Both valve types have an adequate safety profile and are comparable to conventional sutured prostheses. There was a significant reduction in cross-clamp and CPB times associated with SURD. This may be of benefit for patients requiring multiple concomitant procedures and increases the utility of minimally invasive valve replacement. However, SURD was associated with higher post-operative transvalvular gradients and a higher incidence of paravalvular regurgitation.
在工业化国家，主动脉瓣疾病的治疗是最常见的瓣膜手术，80岁以上人群中3% - 9%至少患有中度主动脉瓣狭窄。随着经导管主动脉瓣置换术（TAVR）的日益成熟，已开发出多种新型外科假体，其具有多种锚固系统，并非仅依靠缝线将瓣膜固定在合适位置。爱德华兹Intuity瓣膜是一种牛心包假体，它以广泛植入的Perimount MagnaEase主动脉假体为模型。Perceval瓣膜是一种附着在自膨胀镍钛诺支架上的牛心包瓣膜，它利用支架部分对患者主动脉瓣环和主动脉根部施加的径向力将瓣膜固定在适当位置。本荟萃分析比较了这两种瓣膜系统的对比研究结果。
本系统评价和荟萃分析比较了快速部署瓣膜（RDV）和无缝线瓣膜（SURD）的结果，并按照系统评价和荟萃分析的首选报告项目（PRISMA）建议和指南进行。检索策略查询了六个电子数据库。测量的结果包括最新随访时的全因死亡率、中风、主动脉阻断和体外循环（CPB）时间、起搏器植入率、瓣周漏和术后跨瓣压差。
检索策略识别出407篇独特论文用于初步评估，其中七项研究符合纳入分析的条件。纳入了4076例患者的结果（1650例RDV，2426例SURD）。两组在死亡率、中风或中度及以上瓣周反流方面无差异。与RDV相比，SURD的CPB时间显著缩短15.7分钟[95%置信区间（CI）：4.2 - 27.1；P = 0.007]，主动脉阻断时间缩短11.3分钟（95% CI：6.3 - 16.3；P < 0.001）。RDV术后跨瓣压差低2.5 mmHg（95% CI：1.2 - 3.8；P < 0.001），轻度瓣周反流发生率较低（比值比2.51；95% CI：1.435 - 4.768；P = 0.004）。
两种瓣膜类型都有足够的安全性，与传统缝合假体相当。SURD相关的主动脉阻断和CPB时间显著缩短。这可能对需要同时进行多种手术的患者有益，并增加了微创瓣膜置换的实用性。然而，SURD与术后较高的跨瓣压差和较高的瓣周反流发生率相关。
