室间隔心肌切除术与化学消融术治疗肥厚型梗阻性心肌病临床效果Meta分析

Septal myectomy versus alcohol septal ablation for hypertrophic obstructive cardiomyopathy: a Meta-analysis

目的应用Meta分析的方法评价室间隔心肌切除术(SM)与化学消融术(ASA)治疗肥厚型梗阻性心肌病(HOCM)的临床效果。方法计算机检索PubMed,Embase,Cochrane图书馆,CNKI、CBM disc及VIP里的比较SM和ASA治疗HOCM的对照研究。文献检索时间从建库至2013年10月。根据The Newcastle-Ottawa Scale(NOS)量表评价纳入文献的质量并提取资料。对符合质量标准的对照研究采用Rev Man 5.2进行异质性检验及Meta分析。结果检出相关文献380篇,根据纳入标准最终入选10篇文献;共入选病例927例。SM组与ASA组在术后住院病死率(OR:0.90;95%CI:0.23~3.47)、术后随访期病死率(OR:1.01;95%CI:0.60~1.70)上未见明显差异(分别P=0.88,P=0.97)。两组患者手术前后左心室流出道压差(LVOTG)的下降和NYHA分级的提高均有意义(P<0.05);与ASA组相比,SM组患者的LVOTG下降(SMD:-0.46;95%CI:-0.6 0~0.32)及术后NYHA分级提高(SMD:-0.40;95%CI:-0.62^-0.17)均更为明显,差异有统计学意义(均P<0.01)。SM组在术后右束支传导阻滞(OR:0.08;95%CI:0.03~0.23;P<0.01)、完全性传导阻滞(OR:0.27;95%CI:0.11~0.70;P<0.01)、室性心律失常(OR:0.17;95%CI:0.04~0.75;P=0.02)及安装永久性起搏器(OR:0.22;95%CI:0.13~0.38;P<0.01)的发生率上均较ASA组明显降低。两组患者在术后植入性除颤器的安装率(OR:0.73;95%CI:0.31~1.71)上未见统计学差异(P=0.46)。结论 SM仍然是治疗药物难治性HOCM的金标准;ASA作为一种替代治疗,远期结果需要进一步的观察和随访。

Objective To conduct a meta-analysis of published studies comparing septal myectomy（SM） and alcohol septal ablation（ASA） for hypertrophic obstructive cardiomyopathy（HOCM）. Methods PubMed, Embase, the Cochrane Controlled Trials Register databases, CNKI, CBM disc and VIP databases were searched, and study eligibility and conducted data abstraction were determined independently and in duplicate. Literatures were searched from the date of database establishment to October 2013. The heterogeneity and data were analyzed by the software of Rev Man 5.2. Results Of 380 studies identified, 10 studies met eligibility criteria, and included a total of 927 patients. There was no significant difference in the incidence of hospital mortality（OR： 0.90, 95% CI： 0.23-3.47; P=0.88） and mortality rate in follow up period（OR： 1.01, 95% CI： 0.60-1.70; P=0.97） between SM group and ASA group. The postoperative left ventricular outflow tract gradient（SMD：-0.46; 95% CI：-0.60-0.32） and New York Heart Association class（SMD：-0.40; 95% CI：-0.62--0.17） were significantly decreased respectively（both P〈0.01） in SM group than in ASA group. Similar results were shown in the incidence of postoperative right bundle branch block（OR： 0.08, 95% CI： 0.03-0.23; P〈0.01）, complete heart Block（OR： 0.27, 95% CI： 0.11-0.70; P〈0.01）, ventricular arrhythmia（OR： 0.17, 95% CI： 0.04-0.75; P=0.02）, permanent pacemaker（OR： 0.22, 95% CI： 0.13-0.38; P〈0.01）. There was no significant difference in postoperative implantable cardioverter-defibrillator（OR： 0.73, 95% CI： 0.31-1.71; P=0.46） between SM group and ASA group. Conclusion SM is the first consideration for the majority of eligible patients with HOCM. When surgery is contraindicated or the risk is considered, ASA might be beneficial in HOCM patients, and long-term follow-up observations are required.