Khairallah Sherif, Rahouma Mohamed, Dabsha Anas, Demetres Michelle, Gaudino Mario Fl, Mick Stephanie L
Cardiothoracic Surgery Department, Weill Cornell Medicine New York-Presbyterian Hospital (WCM), New York, NY, USA.
Scholarly Communications Librarian, Weill Cornell Medicine (WCM), Samuel J. Wood Library & C.V. Starr Biomedical Information Center, New York, NY, USA.
Eur J Cardiothorac Surg. 2023 Feb 3;63(2). doi: 10.1093/ejcts/ezac587.
Repair of the isolated degenerative anterior mitral leaflet has been considered more challenging and associated with compromised durability compared with isolated posterior leaflet in major series. Implantation of neochordae or Alfieri edge-to-edge is the most employed repair technique for isolated anterior repair currently, but little data exist comparing their relative durability. We sought to investigate this issue with this meta-analysis.
A literature search was performed (Ovid MEDLINE, Ovid Embase and The Cochrane Library). The primary outcome was the incidence rate (IR) of reoperation, the secondary outcomes were recurrent moderately severe/severe mitral regurgitation (MR), in-hospital/30-day reoperation and mortality and follow-up mortality. A random-effect model was used. Leave-one-out, subgroup analysis (Alfieri versus neochordae) and meta-regression were done.
Seventeen studies (including 1358 patients) were included. At a weighted mean follow-up of 5.56 ± 3.31 years, the IR for reoperation was 14.45 event per 1000 person-year and significantly lower in Alfieri than neochordae repair (9.40 vs 18.61, P = 0.04) on subgroup analysis. The IR of follow-up moderately severe/severe MR was 19.89 event per 1000 person-year and significantly lower in Alfieri than neochordae repair (10.68 and 28.63, P = 0.01). In a sensitivity analysis comparing homogenous studies, a significant difference in the recurrence of regurgitation in favour of the Alfieri approach remained. There were no differences in operative outcomes or survival. There were significant associations between increased incidence of late reoperation and New York Heart Association class III/IV and associated coronary artery bypass graft procedure for whole cohort.
Alfieri repair may be associated with a lower incidence of recurrent MR compared with neochordae-based repair in the setting of isolated degenerative anterior mitral pathology. This is the first such meta-analysis and further inquiry into this area is needed.
在主要系列研究中，与单纯后叶修复相比，单纯退行性二尖瓣前叶修复被认为更具挑战性且耐久性较差。目前，植入新腱索或阿尔菲里缘对缘修复是单纯前叶修复最常用的技术，但比较它们相对耐久性的数据很少。我们试图通过这项荟萃分析来研究这个问题。
进行文献检索（Ovid MEDLINE、Ovid Embase和Cochrane图书馆）。主要结局是再次手术的发生率（IR），次要结局是中度严重/重度二尖瓣反流（MR）复发、住院/30天再次手术及死亡率和随访死亡率。采用随机效应模型。进行留一法分析、亚组分析（阿尔菲里与新腱索）和Meta回归。
纳入17项研究（共1358例患者）。加权平均随访5.56±3.31年，再次手术的IR为每1000人年14.45次事件，亚组分析显示阿尔菲里修复组明显低于新腱索修复组（9.40对18.61，P=0.04）。随访中度严重/重度MR的IR为每1000人年19.89次事件，阿尔菲里修复组明显低于新腱索修复组（10.68和28.63，P=0.01）。在比较同类研究的敏感性分析中，反流复发率仍存在有利于阿尔菲里方法的显著差异。手术结局或生存率无差异。整个队列中，再次手术发生率增加与纽约心脏协会III/IV级及相关冠状动脉搭桥手术之间存在显著关联。
在单纯退行性二尖瓣前叶病变的情况下，与基于新腱索的修复相比，阿尔菲里修复可能与MR复发率较低相关。这是首次此类荟萃分析，该领域还需要进一步研究。
