Zhang Yi, Fu Guangguo, Li Gang, Jian Bohao, Wang Rui, Huang Yang, Chu Tongxin, Wu Zhongkai, Zhou Zhuoming, Liang Mengya
Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
Department of Cardiology, Guangzhou Hospital of Integrated Traditional and West Medicine, Guangzhou, China.
Heart Lung Circ. 2025 Jan;34(1):3-15. doi: 10.1016/j.hlc.2024.07.015. Epub 2024 Nov 29.
Mitral valve repair (MVr) is associated with more favourable long-term outcomes than mitral valve replacement (MVR) in cases of isolated mitral valve disease suitable for repair. However, there is debate regarding whether the superiority of MVr extends to patients with concomitant aortic and mitral valve disease. Therefore, this meta-analysis was conducted to compare the survival benefits between aortic valve replacement (AVR) plus MVr with a double valve replacement (DVR).
A comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane until 20 October 2022. Studies comparing MVr and MVR in patients undergoing concomitant AVR were included. The primary outcome was long-term survival. The secondary outcomes were early mortality, mitral valve reoperation, and valve-related adverse events.
Sixteen studies with a total of 140,638 patients were included in this analysis. Patients undergoing AVR plus MVr exhibited a favourable trend in long-term survival (HR 0.85; 95% CI 0.71-1.03; p=0.10; I=58%). The reconstructed Kaplan-Meier curve revealed that the long-term survival at 5, 10, and 15 years was higher in the AVR plus MVr (80.95%, 67.63%, and 51.18%, respectively) than in the DVR group (76.62%, 61.36%, 43.21%, respectively). Aortic valve replacement plus MVr had a lower risk of early mortality (RR 0.67; 95% CI 0.58-0.79; p<0.001; I=77%), thromboembolic events (RR 0.81; 95% CI 0.67-0.98; p=0.03; I=5%), and haemorrhagic events (RR 0.87; 95% CI 0.78-0.98; p=0.01; I=59%). Moreover, both groups displayed comparable rates of mitral valve reoperation (HR 1.73; 95% CI 0.86-3.48; p=0.13; I=60%) and infective endocarditis (RR 1.60; 95% CI 0.65-3.93; p=0.31; I=0%). However, the rate of reoperation for AVR plus MVr significantly increased in rheumatic heart disease patients (HR 3.30, 95% CI 1.66-6.59; p<0.0001).
Compared with DVR, AVR plus MVr was associated with favourable long-term survival, reduced early mortality risk, and a lower incidence of thromboembolic and haemorrhagic events without increasing the risk of mitral valve reoperation or infective endocarditis in unselected patients. However, higher reoperation rates were observed in rheumatic heart disease patients undergoing AVR plus MVr.
在适合修复的单纯二尖瓣疾病病例中，二尖瓣修复术（MVr）与比二尖瓣置换术（MVR）更有利的长期预后相关。然而，关于MVr的优势是否扩展到合并主动脉瓣和二尖瓣疾病的患者存在争议。因此，进行了这项荟萃分析，以比较主动脉瓣置换术（AVR）加MVr与双瓣置换术（DVR）之间的生存获益。
截至2022年10月20日，在PubMed、EMBASE和Cochrane上进行了全面的文献检索。纳入比较接受同期AVR患者的MVr和MVR的研究。主要结局是长期生存。次要结局是早期死亡率、二尖瓣再次手术和瓣膜相关不良事件。
本分析纳入了16项研究，共140638例患者。接受AVR加MVr的患者在长期生存方面呈现出有利趋势（风险比[HR]0.85；95%置信区间[CI]0.71 - 1.03；p = 0.10；异质性指数[I] = 58%）。重建的Kaplan-Meier曲线显示，AVR加MVr组在5年、10年和15年的长期生存率分别为80.95%、67.63%和51.18%，高于DVR组（分别为76.62%、61.36%、43.21%）。AVR加MVr的早期死亡风险较低（RR 0.67；95% CI 0.58 - 0.79；p < 0.001；I = 77%），血栓栓塞事件（RR 0.81；95% CI 0.67 - 0.98；p = 0.03；I = 5%）和出血事件（RR 0.87；95% CI 0.78 - 0.98；p = 0.01；I = 59%）。此外，两组二尖瓣再次手术率（HR 1.73；95% CI 0.86 - 3.48；p = 0.13；I = 60%）和感染性心内膜炎发生率（RR 1.60；95% CI 0.65 - 3.93；p = 0.31；I = 0%）相当。然而，在风湿性心脏病患者中，AVR加MVr的再次手术率显著增加（HR 3.30，95% CI 1.66 - 6.59；p < 0.0001）。
与DVR相比，AVR加MVr与有利的长期生存、降低的早期死亡风险以及血栓栓塞和出血事件发生率较低相关，且在未选择的患者中不增加二尖瓣再次手术或感染性心内膜炎的风险。然而，在接受AVR加MVr的风湿性心脏病患者中观察到较高的再次手术率。
