经导管主动脉瓣置换术与外科主动脉瓣置换术在中低危重度主动脉瓣狭窄患者中疗效的Meta分析

Transcatheter or Surgical Aortic Valve Replacement in Low and Intermediate-risk Patients With Severe Aortic Stenosis:a Meta-analysis

目的:比较经导管主动脉瓣置换术(TAVR)与外科主动脉瓣置换术(SAVR)在中低危重度主动脉瓣狭窄患者中的治疗效果。方法:通过检索PubMed、Embase、Cochrane图书馆数据库收集关于TAVR在中危或低危重度主动脉狭窄患者中应用的临床研究进行Meta分析。结果:共纳入6项研究6891例患者,TAVR组与SAVR组相比,在术后1年及以上的临床复合终点事件(20.7%vs.20.5%,RR=0.82,95%CI:0.63~1.08,P=0.16)、全因死亡率(16.6%vs.15.6%,RR=0.95,95%CI:0.75~1.20,P=0.67)、心血管死亡率(9.9%vs.10.2%,RR=0.83,95%CI:0.62~1.12,P=0.23)、致残性脑卒中(3.5%vs.4.3%,RR=0.65,95%CI:0.41~1.04,P=0.07)、再住院率(12.9%vs.12.3%,RR=0.94,95%CI:0.65~1.36,P=0.73)、心肌梗死发生率(4.3%vs.3.4%,RR=1.27,95%CI:0.99~1.63,P=0.06)方面的差异均无统计学意义。但TAVR组较SAVR组术后1年以上的再手术风险(1.8%vs.0.6%,RR=2.97,95%CI:1.72~5.12,P<0.01)、需永久起搏器植入的风险(20.1%vs.8.2%,RR=2.94,95%CI:1.63~5.29,P<0.01)均更高,但新发心房颤动的风险更低(13.3%vs.37.6%,RR=0.35,95%CI:0.27~0.46,P<0.01)。亚组分析显示,置入自膨胀式TAVR瓣膜较SAVR可降低致残性脑卒中发生风险(1.8%vs.3.5%,RR=0.51,95%CI:0.34~0.76,P<0.01),而置入球囊扩张式TAVR瓣膜与SAVR相比,术后永久起搏器植入风险相当(13.6%vs.11.1%,RR=1.23,95%CI:0.98~1.56,P=0.08)。结论:对于中低危的重度主动脉瓣狭窄患者,TAVR可作为SAVR的替代方案,但需要注意术后因传导阻滞导致需要植入永久起搏器的风险。

Objectives:To evaluate the efficacy of transcatheter aortic valve replacement(TAVR)and surgical aortic valve replacement(SAVR)in the treatment of low and intermediate-risk patients with severe aortic stenosis.Methods:PubMed,Embase,and the Cochrane Library databases were searched.The meta-analysis is based on obtained large clinical trials in severe aortic stenosis patients with low and intermediate risk.Results:A total of 6 clinical trials including 6891 patients were included.The results of meta-analysis showed that there were no significant differences in composite endpoints(20.7%vs.20.5%,RR=0.82,95%CI:0.63-1.08,P=0.16),allcause mortality(16.6%vs.15.6%,RR=0.95,95%CI:0.75-1.20,P=0.67),cardiovascular mortality(9.9%vs.10.2%,RR=0.83,95%CI:0.62-1.12,P=0.23),disabling stroke(3.5%vs.4.3%,RR=0.65,95%CI:0.41-1.04,P=0.07),rehospitalization(12.9%vs.12.3%,RR=0.94,95%CI:0.65-1.36,P=0.73),incidence of myocardial infarction(4.3%vs.3.4%,RR=1.27,95%CI:0.99-1.63,P=0.06)between TAVR and SAVR groups.The risk of reintervention over 1 year after procedure was higher in the TAVR group than that in the SAVR group(1.8%vs.0.6%,RR=2.97,95%CI:1.72-5.12,P<0.01).The patients in the TAVR group had a higher risk of requiring permanent pacemaker implantation than those of SAVR group(20.1%vs.8.2%,RR=2.94,95%CI:1.63-5.29,P<0.01),but a lower risk of new-onset atrial fibrillation(13.3%vs.37.6%,RR=0.35,95%CI:0.27-0.46,P<0.01).The subgroup analysis showed that self-expandable TAVR valve implantation could reduce the incidence of disabling stroke compared with SAVR group(1.8%vs.3.5%,RR=0.51,95%CI:0.34-0.76,P<0.01),and had a similar risk of permanent pacemaker implantation rate to that of SAVR(13.6%vs.11.1%,RR=1.23,95%CI:0.98-1.56,P=0.08).Conclusions:TAVR can be used as an alternative to SAVR in the treatment of low and intermediate risk patients with severe aortic stenosis.The issue of higher permanent pacemaker implantation rate due to postoperative conduction system block in patients undergoing TAVR should be concerned.