Costa Gonçalo Nuno Ferraz, Cardoso João Fernandes Lopes, Oliveiros Bárbara, Gonçalves Lino, Teixeira Rogerio
Serviço de Cardiologia, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal
Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
Heart. 2023 Jan 27;109(4):314-321. doi: 10.1136/heartjnl-2022-321411.
Timing of intervention for patients with asymptomatic severe aortic stenosis (AS) remains controversial. To compare the outcomes of early aortic valve replacement (AVR) versus watchful waiting (WW) in patients with asymptomatic severe AS.
We systematically searched PubMed, Embase and Cochrane databases, in December 2021, for studies comparing early AVR with WW in the treatment of asymptomatic severe AS. Random-effects meta-analysis was performed.
Twelve studies were included in which two were randomised clinical trials. A total of 4130 patients were included, providing a 1092 pooled death events. Our meta-analysis showed a significantly lower all-cause mortality for the early AVR compared with WW group, although with a high amount of heterogeneity between studies in the magnitude of the effect (pooled OR 0.40; 95% CI 0.35 to 0.45, p<0.01; I²=61%). An early surgery strategy displayed a significantly lower cardiovascular mortality (pooled OR 0.33; 95% CI 0.19 to 0.56, p<0.01; I²=64%) and heart failure hospitalisation (pooled OR 0.19; 95% CI 0.10 to 0.39, p<0.01, I²=7%). However, both groups had similar rates of stroke (pooled OR 1.30; 95% CI 0.73 to 2.29, p=0.36, I²=0%) and myocardial infarction (pooled OR 0.49; 95% CI 0.19 to 1.27, p=0.14, I²= 0%).
This study suggests that for patients with asymptomatic severe AS an early surgical intervention compared with a conservative WW strategy was associated with a lower heart failure hospitalisation and a similar rate of stroke or myocardial infarction, although with significant risk of bias.
CRD42021291144.
无症状重度主动脉瓣狭窄（AS）患者的干预时机仍存在争议。比较无症状重度AS患者早期主动脉瓣置换术（AVR）与观察等待（WW）的疗效。
2021年12月，我们系统检索了PubMed、Embase和Cochrane数据库，以查找比较早期AVR与WW治疗无症状重度AS的研究。进行随机效应荟萃分析。
纳入12项研究，其中2项为随机临床试验。共纳入4130例患者，有1092例合并死亡事件。我们的荟萃分析显示，与WW组相比，早期AVR组的全因死亡率显著降低，尽管各研究间效应大小存在高度异质性（合并比值比0.40；95%置信区间0.35至0.45，p<0.01；I²=61%）。早期手术策略显示心血管死亡率显著降低（合并比值比0.33；95%置信区间0.19至0.56，p<0.01；I²=64%），心力衰竭住院率也显著降低（合并比值比0.19；95%置信区间0.10至0.39，p<0.01，I²=7%）。然而，两组的卒中发生率（合并比值比1.30；95%置信区间0.73至2.29，p=0.36，I²=0%）和心肌梗死发生率（合并比值比0.49；95%置信区间0.19至1.27，p=0.14，I²=0%）相似。
本研究表明，对于无症状重度AS患者，与保守的WW策略相比，早期手术干预与较低的心力衰竭住院率以及相似的卒中和心肌梗死发生率相关，尽管存在显著的偏倚风险。
PROSPERO注册号：CRD42021291144。
