Ahmed Adham, Awad Ahmed K, Varghese Kathryn S, Mathew Joshua, Huda Shayan, George Jerrin, Mathew Serena, Abdelnasser Omar A, Awad Ayman K, Mathew Dave M
City University of New York School of Medicine, NY, USA.
Faculty of Medicine, Ain Shams University, Cairo, Egypt.
Innovations (Phila). 2023 Sep-Oct;18(5):424-434. doi: 10.1177/15569845231197224. Epub 2023 Sep 2.
Transcatheter aortic valve replacement (TAVR) has arisen as a viable alternative to surgery. Similarly, minimally invasive surgical aortic valve replacement (mini-SAVR), such as ministernotomy and minithoracotomy, have also gained interest. We conducted a pairwise meta-analysis to further investigate the efficacy of TAVR versus mini-SAVR.
Medical databases were comprehensively searched for studies comparing TAVR with a mini-SAVR modality, defined as minimally invasive aortic surgery, ministernotomy, minithoracotomy, or rapid-deployment or sutureless SAVR. Random-effects meta-analysis was conducted using the generic inverse variance method. Primary outcomes included 30-day mortality, midterm mortality, 30-day stroke, acute kidney injury (AKI), paravalvular leak (PVL), new permanent pacemaker (PPM), new-onset atrial fibrillation, and postintervention mean and peak valve pressure gradients and were pooled as risk ratio (RR), mean difference (MD), or hazard ratio (HR) with 95% confidence interval (CI).
A total of 5,071 patients (2,505 mini-SAVR vs 2,566 TAVR) from 12 studies were pooled. Compared with TAVR, mini-SAVR showed significantly lower rates of both 30-day (RR = 0.63, 95% CI: 0.42 to 0.96, = 0.03) and midterm mortality at 4 years of follow-up (HR = 0.76, 95% CI: 0.67 to 0.87, < 0.001). Furthermore, mini-SAVR was protective against 30-day PVL (RR = 0.07, 95% CI: 0.04 to 0.13, < 0.001) and new PPM (RR = 0.25, 95% CI: 0.11 to 0.57, < 0.001). Conversely, TAVR was protective against 30-day AKI (RR = 1.67, 95% CI: 1.20 to 2.32, = 0.002) and postinterventional mean gradients (MD = 1.65, 95% CI: 0.25 to 3.05, = 0.02). No difference was observed for 30-day stroke (RR = 0.84, 95% CI: 0.56 to 1.24, = 0.38), new-onset atrial fibrillation (RR = 1.79, 95% CI: 0.93 to 3.44, = 0.08), or postinterventional peak gradients (MD = 3.24, 95% CI: -1.10 to 7.59, = 0.14).
Compared with TAVR, mini-SAVR was protective against 30-day and midterm mortality, 30-day PVL, and new permanent pacemaker, while TAVR patients had lower 30-day AKI. Future randomized trials comparing the efficacy of mini-SAVR approaches with TAVR are needed.
经导管主动脉瓣置换术（TAVR）已成为一种可行的手术替代方案。同样，微创外科主动脉瓣置换术（mini-SAVR），如胸骨上段小切口和胸腔镜小切口手术，也受到了关注。我们进行了一项成对荟萃分析，以进一步研究TAVR与mini-SAVR的疗效。
全面检索医学数据库，查找比较TAVR与mini-SAVR术式的研究，mini-SAVR术式定义为微创主动脉手术、胸骨上段小切口、胸腔镜小切口手术，或快速部署或无缝合主动脉瓣置换术。采用通用逆方差法进行随机效应荟萃分析。主要结局包括30天死亡率、中期死亡率、30天卒中、急性肾损伤（AKI）、瓣周漏（PVL）、新的永久性起搏器（PPM）、新发房颤，以及干预后平均和峰值瓣膜压力梯度，并汇总为风险比（RR）、平均差（MD）或风险比（HR），并给出95%置信区间（CI）。
汇总了12项研究中的5071例患者（2505例mini-SAVR vs 2566例TAVR）。与TAVR相比，mini-SAVR在30天（RR = 0.63，95%CI：0.42至0.96，P = 0.03）和4年随访期的中期死亡率（HR = 0.76，95%CI：0.67至0.87，P < 0.001）方面均显著较低。此外，mini-SAVR可预防30天PVL（RR = 0.07，95%CI：0.04至0.13，P < 0.001）和新的PPM（RR = 0.25，95%CI：0.11至0.57，P < 0.001）。相反，TAVR可预防30天AKI（RR = 1.67，95%CI：1.20至2.32，P = 0.002）和干预后平均梯度（MD = 1.65，95%CI：0.25至3.05，P = 0.02）。30天卒中（RR = 0.84，95%CI：0.56至1.24，P = 0.38）、新发房颤（RR = 1.79，95%CI：0.93至3.44，P = 0.08）或干预后峰值梯度（MD = 3.24，95%CI：-1.10至7.59，P = 0.14）方面未观察到差异。
与TAVR相比，mini-SAVR可预防30天和中期死亡率、30天PVL和新的永久性起搏器，而TAVR患者的30天AKI发生率较低。未来需要进行比较mini-SAVR与TAVR疗效的随机试验。
