Rehabilitation Division Treatment Department, Wang Jing Hospital of China Academy of Chinese Medical Science, Beijing, China.
Department of Vascular Surgery, Wang Jing Hospital of China Academy of Chinese Medical Science, Beijing, China.
Medicine (Baltimore). 2021 Nov 12;100(45):e27657. doi: 10.1097/MD.0000000000027657.
Currently, the number of severe aortic stenosis (AS) patients with a history of prior cardiac surgery (PCS) has increased. Both transcatheter aortic valve replacement (TAVR) and traditional surgical aortic valve replacement (sAVR) are effective therapy for AS. However, PCS increases the risk of adverse outcomes in patients undergoing aortic valve replacement. Thus, this meta-analysis was designed to comparatively evaluate the impact of PCS on clinical outcomes between TAVR and sAVR.
A systematic search of PubMed, Embase, Cochrane Library, and Web of Science up to February 1, 2021 was conducted for relevant studies that comparing TAVR and sAVR for severe AS patients with a history of PCS. The primary outcome was the non-inferiority of TAVR and sAVR in mortality. The secondary outcomes were the other clinical outcomes. Two reviewers assessed trial quality and extracted the data independently. All statistical analyses were performed using the standard statistical procedures provided in Review Manager 5.2.
A total of 11 studies including 8852 patients were identified. The pooled results indicated that there was no difference in 30-day, and 1-year all-cause mortality between TAVR and sAVR. No significant difference was also observed in total follow-up and cardiovascular mortality between TAVR and sAVR. However, subgroup analysis revealed significantly higher 1-year all-cause mortality (OR 1.92; 95% CI 1.05-3.52; P = .04) and total follow-up mortality (OR 2.28; 95% CI 1.09-4.77; P = .03) in TAVR than sAVR for patients with a history of coronary artery bypass graft, aortic valve replacement, and mitral valve reconstruction. In addition, TAVR experienced higher pacemaker implantation than sAVR. However, compared with sAVR, TAVR experienced shorter length of stay (MD -3.18 days; 95% CI -4.78 to -1.57 days) and procedural time (MD -172.01 minutes; 95% CI -251.15 to -92.88) respectively. TAVR also lead to much less bleeding than sAVR.
Our analysis shows that TAVR as a redo procedure was equal to sAVR in mortality for severe AS patients with PCS, especially coronary artery bypass graft. We agree the advantage of TAVR as a redo procedure for patients with a history of PCS. Patients receiving TAVR experienced rapid recovery, shorter operation time and less bleeding, without increasing short and long term mortality.
目前，有既往心脏手术（PCS）史的严重主动脉瓣狭窄（AS）患者数量有所增加。经导管主动脉瓣置换术（TAVR）和传统的主动脉瓣置换术（sAVR）都是治疗 AS 的有效方法。然而，PCS 增加了主动脉瓣置换术患者不良结局的风险。因此，本荟萃分析旨在比较 PCS 对 TAVR 和 sAVR 治疗有 PCS 史的严重 AS 患者临床结局的影响。
系统检索 PubMed、Embase、Cochrane 图书馆和 Web of Science 数据库，截至 2021 年 2 月 1 日，查找比较 TAVR 和 sAVR 治疗有 PCS 史的严重 AS 患者的相关研究。主要结局为 TAVR 和 sAVR 在死亡率方面的非劣效性。次要结局为其他临床结局。两名审查员独立评估试验质量并提取数据。使用 Review Manager 5.2 提供的标准统计程序进行所有统计分析。
共纳入 11 项研究，包括 8852 例患者。汇总结果表明，TAVR 和 sAVR 组 30 天和 1 年全因死亡率无差异。TAVR 和 sAVR 组总随访和心血管死亡率也无显著差异。然而，亚组分析显示，对于有冠状动脉旁路移植术、主动脉瓣置换术和二尖瓣重建术史的患者，TAVR 组 1 年全因死亡率（OR 1.92；95%CI 1.05-3.52；P=0.04）和总随访死亡率（OR 2.28；95%CI 1.09-4.77；P=0.03）均显著高于 sAVR 组。此外，TAVR 组比 sAVR 组更常需要植入起搏器。然而，与 sAVR 相比，TAVR 组的住院时间（MD-3.18 天；95%CI-4.78 至-1.57 天）和手术时间（MD-172.01 分钟；95%CI-251.15 至-92.88 分钟）更短。TAVR 组的出血量也明显少于 sAVR 组。
我们的分析表明，对于有 PCS 史的严重 AS 患者，TAVR 作为一种再手术方法与 sAVR 在死亡率方面相当，尤其是对于冠状动脉旁路移植术患者。我们同意 TAVR 作为 PCS 史患者的再手术方法的优势。接受 TAVR 的患者恢复迅速，手术时间更短，出血更少，且不会增加短期和长期死亡率。
