1
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Filla T, Schwender H, Kuss O. Balancing versus modelling in weighted analysis of non-randomised studies with survival outcomes: A simulation study. Stat Med 2024; 43:3140-3163. [PMID: 38801062 DOI: 10.1002/sim.10110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 09/26/2023] [Accepted: 04/28/2024] [Indexed: 05/29/2024]
Abstract
Weighting methods are widely used for causal effect estimation in non-randomised studies. In general, these methods use the propensity score (PS), the probability of receiving the treatment given the covariates, to arrive at the respective weights. All of these "modelling" methods actually optimize prediction of the respective outcome, which is, in the PS model, treatment assignment. However, this does not match with the actual aim of weighting, which is eliminating the association between covariates and treatment assignment. In the "balancing" approach, covariates are thus balanced directly by solving systems of numerical equations, explicitly without fitting a PS model. To compare modelling, balancing and hybrid approaches to weighting we performed a large simulation study for a binary treatment and a survival outcome. For maximal practical relevance all simulation parameters were selected after a systematic review of medical studies that used PS methods for analysis. We also introduce a new hybrid method that uses the idea of the covariate balancing propensity score and matching weights, thus avoiding extreme weights. In addition, we present a corrected robust variance estimator for some of the methods. Overall, our simulations results indicate that balancing approach methods work worse than expected. However, among the considered balancing methods, entropy balancing consistently outperforms the variance balancing approach. All methods estimating the average treatment effect in the overlap population perform well with very little bias and small standard errors even in settings with misspecified propensity score models. Finally, the coverage using the standard robust variance estimator was too high for all methods, with the proposed corrected robust variance estimator improving coverage in a variety of settings.
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Affiliation(s)
- Tim Filla
- Department of Medical Biometry and Bioinformatics, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Institute of Rheumatology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Holger Schwender
- Mathematical Institute, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Oliver Kuss
- Centre for Health and Society, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Institute for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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2
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Ahmed A, Awad AK, Varghese KS, Mathew J, Huda S, George J, Mathew S, Abdelnasser OA, Awad AK, Mathew DM. Minimally Invasive Versus Transcatheter Aortic Valve Replacement: An Updated Meta-Analysis and Systematic Review. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:424-434. [PMID: 37658743 DOI: 10.1177/15569845231197224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
OBJECTIVE 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. METHODS 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). RESULTS 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, P = 0.03) and midterm mortality at 4 years of follow-up (HR = 0.76, 95% CI: 0.67 to 0.87, P < 0.001). Furthermore, mini-SAVR was protective against 30-day PVL (RR = 0.07, 95% CI: 0.04 to 0.13, P < 0.001) and new PPM (RR = 0.25, 95% CI: 0.11 to 0.57, P < 0.001). Conversely, TAVR was protective against 30-day AKI (RR = 1.67, 95% CI: 1.20 to 2.32, P = 0.002) and postinterventional mean gradients (MD = 1.65, 95% CI: 0.25 to 3.05, P = 0.02). No difference was observed for 30-day stroke (RR = 0.84, 95% CI: 0.56 to 1.24, P = 0.38), new-onset atrial fibrillation (RR = 1.79, 95% CI: 0.93 to 3.44, P = 0.08), or postinterventional peak gradients (MD = 3.24, 95% CI: -1.10 to 7.59, P = 0.14). CONCLUSIONS 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.
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Affiliation(s)
- Adham Ahmed
- City University of New York School of Medicine, NY, USA
| | - Ahmed K Awad
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Joshua Mathew
- City University of New York School of Medicine, NY, USA
| | - Shayan Huda
- City University of New York School of Medicine, NY, USA
| | - Jerrin George
- City University of New York School of Medicine, NY, USA
| | - Serena Mathew
- City University of New York School of Medicine, NY, USA
| | | | - Ayman K Awad
- Faculty of Medicine, El-Galala University, Suez, Egypt
| | - Dave M Mathew
- City University of New York School of Medicine, NY, USA
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3
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Fong KY, Yap JJL, Chan YH, Ewe SH, Chao VTT, Amanullah MR, Govindasamy SP, Aziz ZA, Tan VH, Ho KW. Network Meta-Analysis Comparing Transcatheter, Minimally Invasive, and Conventional Surgical Aortic Valve Replacement. Am J Cardiol 2023; 195:45-56. [PMID: 37011554 DOI: 10.1016/j.amjcard.2023.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/11/2023] [Accepted: 02/14/2023] [Indexed: 04/05/2023]
Abstract
The landscape of aortic valve replacement (AVR) has evolved dramatically over the years, but time-varying outcomes have yet to be comprehensively explored. This study aimed to compare the all-cause mortality among 3 AVR techniques: transcatheter (TAVI), minimally invasive (MIAVR), and conventional AVR (CAVR). An electronic literature search was performed for randomized controlled trials (RCTs) comparing TAVI with CAVR and RCTs or propensity score-matched (PSM) studies comparing MIAVR with CAVR or MIAVR to TAVI. Individual patient data for all-cause mortality were derived from graphical reconstruction of Kaplan-Meier curves. Pairwise comparisons and network meta-analysis were conducted. Sensitivity analyses were performed in the TAVI arm for high risk and low/intermediate risk, as well as patients who underwent transfemoral (TF) TAVI. A total of 27 studies with 16,554 patients were included. In the pairwise comparisons, TAVI showed superior mortality to CAVR until 37.5 months, beyond which there was no significant difference. When restricted to TF TAVI versus CAVR, a consistent mortality benefit favoring TF TAVI was seen (shared frailty hazard ratio [HR] = 0.86, 95% confidence interval [CI] = 0.76 to 0.98, p = 0.024). In the network meta-analysis involving majority PSM data, MIAVR demonstrated significantly lower mortality than TAVI (HR = 0.70, 95% CI = 0.59 to 0.82) and CAVR (HR = 0.69, 95% CI = 0.59 to 0.80); this association remained compared with TF TAVI but with a lower extent of benefit (HR = 0.80, 95% CI = 0.65 to 0.99). In conclusion, the initial short- to medium-term mortality benefit for TAVI over CAVR was attenuated over the longer term. In the subset of patients who underwent TF TAVI, a consistent benefit was found. Among majority PSM data, MIAVR showed improved mortality compared with TAVI and CAVR but less than the TF TAVI subset, which requires validation by robust RCTs.
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Affiliation(s)
- Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Victor T T Chao
- Department of Cardiothoracic Surgery, National Heart Center Singapore, Singapore
| | | | | | - Zameer Abdul Aziz
- Department of Cardiothoracic Surgery, National Heart Center Singapore, Singapore
| | - Vern Hsen Tan
- Department of Cardiology, Changi General Hospital, Singapore
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4
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Similar 5-Year Survival in Transfemoral and Transapical TAVI Patients: A Single-Center Experience. Bioengineering (Basel) 2023; 10:bioengineering10020156. [PMID: 36829650 PMCID: PMC9952102 DOI: 10.3390/bioengineering10020156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/16/2023] [Accepted: 01/20/2023] [Indexed: 01/27/2023] Open
Abstract
Transapical transcatheter aortic valve implantation (TA-TAVI) is generally considered to be associated with increased morbidity and mortality compared with transfemoral transcatheter aortic valve implantation TAVI (TF-TAVI). We aimed to compare different patient risk profiles, access-related complications, and long-term survival using inverse probability treatment weighting. This is a retrospective, single-center analysis of 925 consecutive patients with aortic valve stenosis undergoing TF-TAVI (n = 802) or TA-TAVI (n = 123) at the University Hospital Basel, Switzerland, as a single procedure between September 2011 and August 2020. Baseline characteristics revealed a higher perioperative risk as reflected in the EuroSCORE II (geometric mean 2.3 (95% confidence interval (CI) 2.2 to 2.4) vs. 3.7 (CI 3.1 to 4.5); before inverse probability of treatment weighting (IPTW) p < 0.001) in the transfemoral than in the transapical group, respectively. After 30 days, TF-TAVI patients had a higher incidence of any bleeding than TA-TAVI patients (TF-TAVI n = 146 vs. TA-TAVI n = 15; weighted hazard ratio (HR) 0.52 (0.29 to 0.95); p = 0.032). After 5 years, all-cause mortality did not differ between the two groups (TF-TAVI n = 162 vs. TA-TAVI n = 45; weighted HR 1.31, (0.92 to 1.88); p = 0.138). With regard to our data, we could demonstrate, despite a higher perioperative risk, the short- and long-term safety and efficacy of the transapical approach for TAVI therapies. Though at higher perioperative risk, transapically treated patients suffered from less bleeding or vascular complications than transfemorally treated patients. It is of utmost interest that 5-year mortality did not differ between the groups.
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5
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Payabyab EC, Elbaum LS, Sharma N, George I, Mick SL. Shockwave and Non-transfemoral Transcatheter Aortic Valve Replacement. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2021.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has become a widely adopted treatment modality for severe aortic stenosis. Transfemoral access is the approach of choice; however, approximately 25% of patients undergoing TAVR also have concomitant peripheral arterial disease. The recent advent of intravascular lithotripsy has enabled preservation of transfemoral access in some patients; although, a proportion still require alternative, non-femoral access. Alternative access sites can be broadly categorized into transthoracic and peripheral, facilitated by surgical or percutaneous techniques. In this review, the technical details and clinical outcomes of various TAVR accesses are discussed. Initially, transthoracic approaches were most common, but recently, the trend has been toward alternative peripheral access due to superior outcomes. Although there are no randomized data to support all the alternative access sites, the experiences reported provide available options for a large portion of patients to be candidates for TAVR. The intervention site should be selected by a multidisciplinary heart team based on patient anatomical factors and institutional expertise.
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Affiliation(s)
- Eden C Payabyab
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, NY
| | - Lindsay S Elbaum
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York City, NY
| | - Navneet Sharma
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York City, NY
| | - Isaac George
- NewYork-Presbyterian Hospital, Columbia University Medical Center, New York City, NY
| | - Stephanie L Mick
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, NY
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6
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Zhao PY, Wang YH, Liu RS, Zhu JH, Wu JY, Song B. The noninferiority of transcatheter aortic valve implantation compared to surgical aortic valve replacement for severe aortic disease: Evidence based on 16 randomized controlled trials. Medicine (Baltimore) 2021; 100:e26556. [PMID: 34260533 PMCID: PMC8284753 DOI: 10.1097/md.0000000000026556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 06/07/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Currently, transcatheter aortic valve implantation (TAVI) as an effective and convenient intervention has been adopted extensively for patients with severe aortic disease. However, the efficacy and safety of TAVI have not yet been well evaluated and its noninferiority compared with traditional surgical aortic valve replacement (sAVR) still lack sufficient evidence. This meta-analysis was designed to comprehensively compare the noninferiority of TAVI with sAVR for patients with severe aortic disease. METHODS A systematic search of PubMed, Embase, Cochrane Library, and Web of Science up to October 1, 2020 was conducted for relevant studies that comparing TAVI and sAVR in the treatment of severe aortic disease. The primary outcomes were early, midterm and long term mortality. The secondary outcomes included early complications and other late outcomes. Two reviewers assessed trial quality and extracted the data independently. All statistical analyzes were performed using the standard statistical procedures provided in Review Manager 5.2. RESULTS A total of 16 studies including 14394 patients were identified. There was no difference in 30-day, 1-year, 2-year, and 5-year all-cause or cardiovascular mortality as well as stroke between TAVI and sAVR. Regarding to the 30-day outcomes, compared with sAVR, TAVI experienced a significantly lower incidence of myocardial infarction (risk ratio [RR] 0.62; 95% confidence interval [CI] 0.40-0.97; 5441 pts), cardiogenic shock (RR 0.34; 95% CI 0.19-0.59; 1936 pts), acute kidney injury (AKI) > stage 2 (RR 0.37; 95% CI 0.25-0.54; 5371 pts), and new-onset atrial fibrillation (NOAF) (RR 0.29; 95% CI 0.24-0.35; 5371 pts) respectively, but higher incidence of permanent pacemaker implantation (RR 3.16; 95% CI 1.61-6.21; 5441 pts) and major vascular complications (RR 2.22; 95% CI 1.14-4.32; 5371 pts). Regarding to the 1- and 2-year outcomes, compared with sAVR, TAVI experienced a significantly lower incidence of NOAF, but higher incidence of neurological events, transient ischemic attacks (TIA), permanent pacemaker and major vascular complications respectively. Regarding to the 5-year outcomes, compared with sAVR, TAVI experienced a significantly lower incidence of NOAF, but higher incidence of TIA and reintervention respectively. CONCLUSIONS Our analysis shows that TAVI was equal to sAVR in early, midterm and long term mortality for patients with severe aortic disease. In addition, TAVI may be favorable in reducing the incidence of both early, midterm and long term NOAF. However, pooled results showed superiority of sAVR in reducing permanent pacemaker implantation, neurological events, TIA, major vascular complications and reintervention.
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Affiliation(s)
- Peng-Ying Zhao
- Department of Cardiovascular Surgery, Lanzhou University First Affiliated Hospital, Lanzhou, China
| | - Yong-Hong Wang
- Department of Cardiovascular Surgery, Qinghai University Affiliated Hospital, Xi’ning, China
- Medical College of Qinghai University, Qinghai University, Xi’ning, China
| | - Rui-Sheng Liu
- Department of Cardiovascular Surgery, Lanzhou University First Affiliated Hospital, Lanzhou, China
| | - Ji-Hai Zhu
- Department of Cardiovascular Surgery, Qinghai University Affiliated Hospital, Xi’ning, China
- Medical College of Qinghai University, Qinghai University, Xi’ning, China
| | - Jian-Ying Wu
- Department of Cardiovascular Surgery, Qinghai University Affiliated Hospital, Xi’ning, China
- Medical College of Qinghai University, Qinghai University, Xi’ning, China
| | - Bing Song
- Department of Cardiovascular Surgery, Lanzhou University First Affiliated Hospital, Lanzhou, China
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7
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Useini D, Beluli B, Christ H, Schlömicher M, Ewais E, Patsalis P, Haldenwang P, Naraghi H, Moustafine V, Bechtel M, Strauch J. Transapical transcatheter aortic valve implantation in patients with aortic diseases. Eur J Cardiothorac Surg 2021; 59:1174-1181. [PMID: 33709139 DOI: 10.1093/ejcts/ezab050] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 12/07/2020] [Accepted: 12/18/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES Patients scheduled for transcatheter aortic valve implantation (TAVI) treatment frequently present with concomitant aortic diseases, in which case they are usually considered to be at high interventional risk and, in particular, unable to undergo the transfemoral TAVI approach. Since the establishment of the 'transfemoral first' strategy for TAVI, there has been an evidence gap with regard to the outcomes of such patients. We aimed to evaluate the mid-term outcomes after transapical TAVI in patients with diverse aortic diseases. METHODS Fifty-five consecutive elderly patients (78.4 years; standard deviation: 8.6 years) at intermediate surgical risk with severe aortic stenosis and aortic diseases (porcelain aorta 36%, ascending aneurysm 15%, descending aneurysm 26%, type-B dissection 4%, aortic thrombus 7%, Leriche syndrome 4%, aortic kinking 11%, aortic ulcer 2%, previous aortic operation 20%, aortic elongation/tortuosity 4%) underwent transapical TAVI treatment between January 2011 and November 2019 at our institution. We used the second-and third-generation self- and balloon-expanding valves. The follow-up time was 92.6 patient-years. RESULTS The Society of Thoracic Surgery-Predicted Risk of Mortality score was 7% (standard deviation: 4%). The 30-day mortality and all-stroke rates were 6% and 4%, respectively. The median survival time was 24.9 months (95% confidence interval 17.6-32.3). The median time of freedom from a composite of death and cardio-cerebral adverse events was 24.3 months (95% confidence interval 11.9-36.8). The rate of moderate/severe paravalvular leakage was 2%. The pacemaker rate was 10%. No early or late aortic syndrome occurred. CONCLUSIONS Transapical TAVI is a safe method and shows very promising early and mid-term outcomes, without early/late aortic syndrome, in patients with aortic diseases for whom transfemoral TAVI as the first-line transcatheter method might be contraindicated or not feasible.
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Affiliation(s)
- Dritan Useini
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Blerta Beluli
- Department of Internal Medicine, St. Anna Hospital, Herne, Germany
| | - Hildegard Christ
- Department of Medical Statistics, Institute of Medical Statistics and Computational Biology (IMSB), University Hospital of Cologne, Cologne, Germany
| | - Markus Schlömicher
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Elias Ewais
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Polykarpos Patsalis
- Department of Cardiology and Angiology, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Peter Haldenwang
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Hamid Naraghi
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Vadim Moustafine
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Matthias Bechtel
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Justus Strauch
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
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8
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Kargoli F, Pagnesi M, Rahgozar K, Goldberg Y, Ho E, Chau M, Colombo A, Latib A. Current Devices and Complications Related to Transcatheter Mitral Valve Replacement: The Bumpy Road to the Top. Front Cardiovasc Med 2021; 8:639058. [PMID: 34179126 PMCID: PMC8230552 DOI: 10.3389/fcvm.2021.639058] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 04/13/2021] [Indexed: 11/18/2022] Open
Abstract
Mitral regurgitation is the most common valvular lesion in the developed world, with increasing prevalence, morbidity, and mortality. The experience with surgical mitral valve repair or replacement is very well-validated. However, more than 45% of these patients get denied surgery due to an elevated risk profile and advanced disease of the left ventricle at the time of presentation, promoting the need for less invasive transcatheter options such as transcatheter repair and transcatheter mitral valve replacement (TMVR). Early available TMVR studies have shown promising results, and several dedicated devices are under clinical evaluation. However, TMVR is still in the early developmental stages and is associated with a non-negligible risk of periprocedural and post-procedural complications. In this review, we discuss the current challenges facing TMVR and the potential TMVR-related complications, offering an overview on the measures implemented to mitigate these complications, and future implications.
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Affiliation(s)
- Faraj Kargoli
- Department of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States
| | - Matteo Pagnesi
- Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Kusha Rahgozar
- Department of Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States
| | - Ythan Goldberg
- Department of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States
| | - Edwin Ho
- Department of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States
| | - Mei Chau
- Department of Cardiothoracic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States
| | - Antonio Colombo
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | - Azeem Latib
- Department of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States
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9
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Doyle MP, Woldendorp K, Ng M, Vallely MP, Wilson MK, Yan TD, Bannon PG. Minimally-invasive versus transcatheter aortic valve implantation: systematic review with meta-analysis of propensity-matched studies. J Thorac Dis 2021; 13:1671-1683. [PMID: 33841958 PMCID: PMC8024828 DOI: 10.21037/jtd-20-2233] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Minimally invasive aortic valve replacement (MiAVR) and transcatheter aortic valve implantation (TAVI) provide aortic valve replacement (AVR) by less invasive methods than conventional surgical AVR, by avoiding complete sternotomy. This study directly compares and analyses the available evidence for early outcomes between these two AVR methods. Methods Electronic databases were searched from inception until August 2019 for studies comparing MiAVR to TAVI, according to predefined search criteria. Propensity-matched studies with sufficient data were included in a meta-analysis. Results Eight studies with 9,744 patients were included in the quantitative analysis. Analysis of risk-matched patients showed no difference in early mortality (RR 0.76, 95% CI, 0.37–1.54, P=0.44). MiAVR had a signal towards lower rate of postoperative stroke, although this did not reach statistical significance (OR 0.42, 95% CI, 0.13–1.29, P=0.13). MiAVR had significantly lower rates of new pacemaker (PPM) requirement (OR 0.29, 95% CI, 0.16–0.52, P<0.0001) and postoperative aortic insufficiency (AI) or paravalvular leak (PVL) (OR 0.05, 95% CI, 0.01–0.20, P<0.0001) compared to TAVI, (OR 0.42, 95% CI, 0.13–1.29, P=0.13), while acute kidney injury (AKI) was higher in MiAVR compared to TAVI (11.1% vs. 5.2%, OR 2.28, 95% CI, 1.25–4.16, P=0.007). Conclusions In patients of equivalent surgical risk scores, MiAVR may be performed with lower rates of postoperative PPM requirement and AI/PVL, higher rates of AKI and no statistical difference in postoperative stroke or short-term mortality, compared to TAVI. Further prospective trials are needed to validate these results.
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Affiliation(s)
- Mathew P Doyle
- The Royal Prince Alfred Hospital, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,University of Wollongong School of Medicine, Keiraville, Australia
| | - Kei Woldendorp
- The Royal Prince Alfred Hospital, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,The University of Sydney Medical School, Camperdown, Australia
| | - Martin Ng
- The Royal Prince Alfred Hospital, Sydney, Australia.,The University of Sydney Medical School, Camperdown, Australia
| | | | - Michael K Wilson
- Macquarie University Hospital, Macquarie University, Sydney, Australia
| | - Tristan D Yan
- The Royal Prince Alfred Hospital, Sydney, Australia.,Macquarie University Hospital, Macquarie University, Sydney, Australia.,Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Paul G Bannon
- The Royal Prince Alfred Hospital, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,The University of Sydney Medical School, Camperdown, Australia
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10
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Thourani VH, Edelman JJ, Holmes SD, Nguyen TC, Carroll J, Mack MJ, Kapadia S, Tang GHL, Kodali S, Kaneko T, Meduri CU, Forcillo J, Ferdinand FD, Fontana G, Suwalski P, Kiaii B, Balkhy H, Kempfert J, Cheung A, Borger MA, Reardon M, Leon MB, Popma JJ, Ad N. The International Society for Minimally Invasive Cardiothoracic Surgery Expert Consensus Statement on Transcatheter and Surgical Aortic Valve Replacement in Low- and Intermediate-Risk Patients: A Meta-Analysis of Randomized and Propensity-Matched Studies. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:3-16. [PMID: 33491539 DOI: 10.1177/1556984520978316] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE There is an increasing amount of evidence supporting use of transcatheter aortic valve replacement (TAVR) for treatment of aortic stenosis in patients at low or intermediate risk for surgical aortic valve replacement (SAVR). TAVR is now approved for use in all patient cohorts. Despite this, there remains debate about the relative efficacy of TAVR compared with SAVR in lower-risk cohorts and various subgroups of patients. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and propensity-matched trials to guide a consensus among expert cardiologists and surgeons. METHODS Studies comparing TAVR and SAVR in low- and intermediate-risk patients were identified by a thorough search of the major databases. Mortality, stroke, and other perioperative outcomes were assessed at 30 days and 1 year. RESULTS Early mortality was lower in TAVR compared to SAVR in RCTs, but not propensity-matched studies in low-risk cohorts (0.66% vs 1.5%; odds ratio [OR] = 0.44, 95% confidence interval [CI] 0.20 to 0.98, I2 = 0%). No difference in mortality between TAVR and SAVR was identified in intermediate-risk patients at early or later time points. Incidence of perioperative stroke in 3 low-risk RCTs was significantly lower in TAVR (0.4%) than SAVR (1.4%; OR = 0.33, 95% CI 0.13 to 0.81, I2 = 0%). There was no difference in stroke for intermediate-risk patients between TAVR and SAVR. The expert panel of cardiologists and cardiac surgeons provided recommendations for TAVR and SAVR in various clinical scenarios. CONCLUSIONS In RCTs comparing TAVR and SAVR in low-risk patients, early mortality and stroke were lower in TAVR, but did not differ at 1 year. There was no difference in mortality and stroke in intermediate-risk patients. The Multidisciplinary Heart Team must consider individual patient characteristics and preferences when recommending TAVR or SAVR. The decision must consider the long-term management of each patient's aortic valve disease.
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Affiliation(s)
- Vinod H Thourani
- 165591 Department of Cardiovascular Surgery, Marcus Heart and Vascular Center, Piedmont Heart and Vascular Institute, Atlanta, GA, USA
| | - J James Edelman
- 2720 Department of Cardiac Surgery, Fiona Stanley Hospital, University of Western Australia, Perth, Australia
| | - Sari D Holmes
- 12264 Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tom C Nguyen
- Division of Adult Cardiothoracic Surgery, University of California, San Francisco, CA, USA
| | - John Carroll
- 1878 Division of Cardiology, University of Colorado, Denver, CO, USA
| | - Michael J Mack
- 384526 Department of Cardiology, Baylor Health Care System, Heart Hospital Baylor Plano, Dallas, TX, USA
| | - Samir Kapadia
- 2569 Department of Cardiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Gilbert H L Tang
- 5944 Department of Cardiovascular Surgery, Mount Sinai Health System, New York, NY, USA
| | - Susheel Kodali
- 5798 Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Tsuyoshi Kaneko
- 1861 Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Christopher U Meduri
- 165591 Division of Cardiology, Marcus Heart and Vascular Center, Piedmont Heart Institute, Atlanta, GA, USA
| | - Jessica Forcillo
- 5622 Department of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Canada
| | - Francis D Ferdinand
- 6595 Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine & UPMC Hamot Heart and Vascular Institute, University of Pittsburgh Medical Center, PA, USA
| | - Gregory Fontana
- Cardiovascular Institute, Los Robles Hospital and Medical Center, Thousand Oaks, CA, USA
| | - Piotr Suwalski
- 359917 Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Bob Kiaii
- 8789 Cardiothoracic Surgery, UC Davis Medical Center, Sacramento, CA, USA
| | - Husam Balkhy
- 12246 Section of Cardiac Surgery, University of Chicago Medicine, IL, USA
| | - Joerg Kempfert
- Department of Cardiac Surgery, German Heart Institute, Berlin, Germany
| | - Anson Cheung
- Department of Cardiac Surgery, The University of British Columbia, St. Paul's Hospital, Vancouver, Canada
| | | | - Michael Reardon
- Department of Cardiac Surgery, Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Martin B Leon
- 5798 Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Jeffrey J Popma
- 1859 Department of Interventional Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Niv Ad
- 12264 Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Cardiovascular Surgery, Adventist White Oak Medical Center, Silver Spring, MD, USA
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11
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Sayed A, Almotawally S, Wilson K, Munir M, Bendary A, Ramzy A, Hirji S, Ibrahim Abushouk A. Minimally invasive surgery versus transcatheter aortic valve replacement: a systematic review and meta-analysis. Open Heart 2021; 8:openhrt-2020-001535. [PMID: 33455914 PMCID: PMC7813322 DOI: 10.1136/openhrt-2020-001535] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 12/23/2020] [Accepted: 12/23/2020] [Indexed: 02/06/2023] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has recently been approved for use in patients who are at intermediate and low surgical risk. Moreover, recent years have witnessed a renewed interest in minimally invasive aortic valve replacement (miAVR). The present meta-analysis compared the outcomes of TAVR and miAVR in the management of aortic stenosis (AS). We conducted an electronic search across six databases from 2002 (TAVR inception) to December 2019. Data from relevant studies regarding the clinical and length of hospitalisation outcomes were extracted and analysed using R software. We identified a total of 11 cohort studies, of which seven were matched/propensity matched. Our analysis demonstrated higher rates of midterm mortality (≥1 year) with TAVR (risk ratio (RR): 1.93, 95% CI: 1.16 to 3.22), but no significant differences with respect to 1 month mortality (RR: 1.00, 95% CI: 0.55 to 1.81), stroke (RR: 1.08, 95% CI: 0.40 to 2.87) and bleeding (RR: 1.45, 95% CI: 0.56 to 3.75) rates. Patients undergoing TAVR were more likely to experience paravalvular leakage (RR: 14.89, 95% CI: 6.89 to 32.16), yet less likely to suffer acute kidney injury (RR: 0.38, 95% CI: 0.21 to 0.69) compared with miAVR. The duration of hospitalisation was significantly longer in the miAVR group (mean difference: 1.92 (0.61 to 3.24)). Grading of Recommendations Assessment, Development and Evaluation assessment revealed ≤moderate quality of evidence in all outcomes. TAVR was associated with lower acute kidney injury rate and shorter length of hospitalisation, yet higher risks of midterm mortality and paravalvular leakage. Given the increasing adoption of both techniques, there is an urgent need for head-to-head randomised trials with adequate follow-up periods.
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Affiliation(s)
- Ahmed Sayed
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Karim Wilson
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Malak Munir
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ahmed Bendary
- Faculty of Medicine, Cardiology, Benha University, Benha, Egypt
| | - Ahmed Ramzy
- Faculty of Medicine, Cardiology, Benha University, Benha, Egypt
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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12
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Alnajar A, Chatterjee S, Chou BP, Khabsa M, Rippstein M, Lee VV, La Pietra A, Lamelas J. Current Surgical Risk Scores Overestimate Risk in Minimally Invasive Aortic Valve Replacement. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2020; 16:43-51. [PMID: 33269957 DOI: 10.1177/1556984520971775] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Risk-scoring systems for surgical aortic valve replacement (AVR) were largely derived from sternotomy cases. We evaluated the accuracy of current risk scores in predicting outcomes after minimally invasive AVR (mini-AVR). Because transcatheter AVR (TAVR) is being considered for use in low-risk patients with aortic stenosis, accurate mini-AVR risk assessment is necessary. METHODS We reviewed 1,018 consecutive isolated mini-AVR cases (2009 to 2015). After excluding patients with Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) scores ≥4, we calculated each patient's European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, TAVR Risk Score (TAVR-RS), and age, creatinine, and ejection fraction score (ACEF). We compared all 4 scores' accuracy in predicting mini-AVR 30-day mortality by computing each score's observed-to-expected mortality ratio (O:E). Area under the receiver operating characteristic (ROC) curves tested discrimination, and the Hosmer-Lemeshow goodness-of-fit tested calibration. RESULTS Among 941 patients (mean age, 72 ± 12 years), 6 deaths occurred within 30 days (actual mortality rate, 0.6%). All 4 scoring systems overpredicted expected mortality after mini-AVR: ACEF (1.4%), EuroSCORE II (1.9%), STS-PROM (2.0%), and TAVR-RS (2.1%). STS-PROM best estimated risk for patients with STS-PROM scores 0 to <1 (0.6 O:E), ACEF for patients with STS-PROM scores 2 to <3 (0.6 O:E), and TAVR-RS for patients with STS-PROM scores 3 to <4 (0.7 O:E). ROC curves showed only fair discrimination and calibration across all risk scores. CONCLUSIONS In low-risk patients who underwent mini-AVR, current surgical scoring systems overpredicted mortality 2-to-3-fold. Alternative dedicated scoring systems for mini-AVR are needed for more accurate outcomes assessment.
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Affiliation(s)
- Ahmed Alnajar
- 158424 Division of Cardiothoracic Surgery, University of Miami, FL, USA
| | - Subhasis Chatterjee
- 3989 Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,14644 Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - Brendan P Chou
- 3989 Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Mariam Khabsa
- 3989 Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Madeline Rippstein
- 3989 Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Vei-Vei Lee
- 14644 Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - Angelo La Pietra
- 5258 Division of Cardiothoracic Surgery, Mount Sinai Medical Center and Heart Institute, Miami Beach, FL, USA
| | - Joseph Lamelas
- 158424 Division of Cardiothoracic Surgery, University of Miami, FL, USA.,3989 Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,14644 Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA.,5258 Division of Cardiothoracic Surgery, Mount Sinai Medical Center and Heart Institute, Miami Beach, FL, USA
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13
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Tamura T, Ito T, Yokota S, Ito S, Kubo Y, Ando M, Nishiwaki K. Incidence of reexpansion pulmonary edema in minimally invasive cardiac surgery. NAGOYA JOURNAL OF MEDICAL SCIENCE 2019; 81:647-654. [PMID: 31849382 PMCID: PMC6892674 DOI: 10.18999/nagjms.81.4.647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Minimally invasive cardiac surgery requires fewer blood transfusions and mediastinitis is less frequently observed compared to conventional median sternotomy surgical intervention, and it leads to earlier recovery and discharge. However, once reexpansion pulmonary edema occurs, the patient requires long-term management in the intensive care unit. This retrospective study was performed to investigate the incidence of reexpansion pulmonary edema in minimally invasive cardiac surgery. Patients who underwent minimally invasive cardiac valve surgery using cardiopulmonary bypass and port-access by a minimal right lateral thoracic incision between January 2010 and January 2018 were enrolled in this single-center retrospective study, which was approved by the institutional review board of Japanese Red Cross Nagoya Daiichi Hospital (Nagoya, Japan), and the requirement for written informed consent was waived. All data were collected from electronic charts. The primary outcome was the incidence rate of reexpansion pulmonary edema in patients undergoing minimally invasive cardiac surgery. A total of 662 patients underwent minimally invasive cardiac surgery, and we analyzed 651 of these cases. No case of reexpansion pulmonary edema was observed in this study. The statistically-calculated incidence rate of reexpansion pulmonary edema was less than 0.6% (95% confidence interval: 0.0–0.6). The incidence of cerebral infarction was 0.92% (n = 6). Intensive care unit stay days, hospital stay days after surgery, and the death rate after 30 days were 1.5 ± 2.0 days, 9.6 ± 3.9 days, and 0.15%, respectively. Although there was no incidence of clinical reexpansion pulmonary edema in this study, the predicted incidence of reexpansion pulmonary edema by statistical analysis was less than 0.6%.
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Affiliation(s)
- Takahiro Tamura
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshiaki Ito
- Division of Cardiac Surgery, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Shuichi Yokota
- Division of Anesthesia, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Shigeki Ito
- Division of Diagnostic Radiology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Yoko Kubo
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Masahiko Ando
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Kimitoshi Nishiwaki
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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14
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Moschovas A, Safarov R, Sandhaus T, Tkebuchava S, Schenkl C, Kirov H, Färber G, Doenst T. Literaturübersicht 2018 zur Herzklappenchirurgie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00398-019-00332-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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15
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Takagi H, Hari Y, Nakashima K, Kuno T, Ando T. A meta-analysis of ≥5-year mortality after transcatheter versus surgical aortic valve replacement. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 61:107-116. [PMID: 31666501 DOI: 10.23736/s0021-9509.19.11030-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION It remains unclear whether long-term survival is superior following transcatheter aortic valve implantation (TAVI) than following surgical aortic valve replacement (SAVR). We performed a meta-analysis of mortality with ≥5-year follow-up in randomized controlled trials (RCTs) and propensity-score matched (PSM) studies of TAVI versus SAVR. EVIDENCE ACQUISITION MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched through March 2019. Eligible studies were RCTs or PSM studies of TAVI versus SAVR enrolling patients with severe aortic stenosis and reporting all-cause mortality with ≥5-year follow-up as an outcome. A hazard ratio of mortality for TAVI versus SAVR was extracted from each individual study. EVIDENCE SYNTHESIS Our search identified 3 RCTs and 7 PSM studies enrolling 5498 patients. A pooled analysis of all 10 studies demonstrated a statistically significant 38% increase in mortality with TAVI relative to SAVR. A subgroup meta-analysis showed no statistically significant difference between TAVI and AVR in RCTs and a statistically significant 68% increase with TAVI relative to SAVR in PSM studies. CONCLUSIONS On the basis of a meta-analysis of 7 PSM studies, TAVI is associated with greater all-cause mortality with ≥5-year follow-up than SAVR. However, another meta-analysis of 3 RCTs suggests no difference in mortality between TAVI and SAVR.
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Affiliation(s)
- Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan - .,Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan -
| | - Yosuke Hari
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan.,Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kouki Nakashima
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan.,Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Toshiki Kuno
- Department of Medicine, Mount Sinai Beth Israel Medical Center, New York, NY, USA
| | - Tomo Ando
- Department of Cardiology, Detroit Medical Center, Detroit, MI, USA
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16
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Fu J, Popal MS, Li Y, Li G, Qi Y, Fang F, Kwong JSW, You B, Meng X, Du J. Transcatheter versus surgical aortic valve replacement in low and intermediate risk patients with severe aortic stenosis: systematic review and meta-analysis of randomized controlled trials and propensity score matching observational studies. J Thorac Dis 2019; 11:1945-1962. [PMID: 31285888 DOI: 10.21037/jtd.2019.04.97] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background To compare the outcome of transcatheter aortic valve replacement (TAVR) with surgical aortic valve replacement (SAVR) in low and intermediate risk patients with severe aortic stenosis (AS). Randomized controlled trials (RCT) and propensity score matching (PSM) studies compare TAVR with SAVR in patients at low and intermediate surgical risk. Methods Two authors searched relevant literature independently, then extracted data from the included studies, and assessed risk of bias and quality of study separately according to different study designs, besides that, the extracted data was analyzed via utilization of GRADE system to evaluate the quality of evidence separately. Results Overall 15 studies (5 RCTs, 10 PSM studies) with total 12,057 patients were selected. Mortality and disabling stroke during follow-up period were comparable between TAVR and SAVR (RR 1.09, 95% CI: 0.81 to 1.46; RR 0.7, 95% CI: 0.45 to 1.07, respectively), TAVR revealed to be superior to SAVR regarding acute kidney injury (AKI), and onset of new atrial fibrillation (AF) (RCT: high certainty; AKI in PSM: moderate certainty, AF in PSM: low certainty). These results of RCT and PSM studies are consistent. In RCT review, SAVR was better in the following aspects: aortic valve (AV) re-intervention (high certainty), vascular complications, pacemaker implantation (moderate certainty), but comparable in the following aspects: myocardial infarction (MI), aortic insufficient (AI) (moderate certainty), major bleeding (low certainty). In PSM review, SAVR revealed a better result in AI and vascular complications (high certainty), but in the aspects of AV re-intervention, pacemaker implantation, major bleeding and MI (low certainty), it was comparable. Conclusions TAVR is comparable to SAVR in terms of mortality and disabling stroke in severe AS patients at low and intermediate risk, but higher proportion of AV re-intervention observed in TAVR. Those results should encourage caution when extending the indications of TAVR into low risk patients, especially for young low risk patients. Systematic review registration PROSPERO CRD 42018112626.
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Affiliation(s)
- Jintao Fu
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | | | - Yulin Li
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Guoqi Li
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yue Qi
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Fang Fang
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Joey S W Kwong
- Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Bin You
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xu Meng
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jie Du
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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17
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Doenst T, Bargenda S, Kirov H, Moschovas A, Tkebuchava S, Safarov R, Diab M, Faerber G. Cardiac surgery 2018 reviewed. Clin Res Cardiol 2019; 108:974-989. [PMID: 30929035 DOI: 10.1007/s00392-019-01470-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 03/22/2019] [Indexed: 12/16/2022]
Abstract
For the year 2018, more than 22,000 published references can be found in PubMed when entering the search term "cardiac surgery". As in the last 4 years, this review focusses on conventional cardiac surgery publications which provide important and interesting information especially relevant for non-surgical colleagues. Interventional techniques have been considered if they were published in the context of classic surgical techniques. We have again reviewed the fields of coronary revascularization and valve surgery and briefly touched on aortic surgery and surgery for terminal heart failure. For revascularization of complex coronary artery disease, bypass grafting was reconfirmed as gold standard and computer-tomographic angiography established equipoise for decision-making with classic angiography. For aortic valve treatment, some new longer-term outcomes from TAVI vs. SAVR trials confirmed equipoise of both treatments for high and medium risk. New information was provided for INR-management of mechanical aortic valves as well as long-term experiences for alternatives to mechanical valves (i.e., Ross and the relatively new Ozaki procedure). In the mitral and tricuspid field, prevalence data illustrate a significant amount of under-treatment for mitral and tricuspid valve regurgitation and evidence for life prolonging-effects of surgery. Finally, elongation of the ascending aorta was identified as new risk factor for aortic dissection and 2 years outcome of the newest generation of left ventricular assist devices demonstrate impressive improvements in outcome. While this article attempts to summarize the most pertinent publications, it does not expect to be complete and cannot be free of individual interpretation. As in recent years, it provides a condensed summary that is intended to give the reader "solid ground" for up-to-date decision-making in cardiac surgery and a stimulus for in-depth reading.
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Affiliation(s)
- Torsten Doenst
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, Am Klinikum 1, 07747, Jena, Germany.
| | - Steffen Bargenda
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Hristo Kirov
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Alexandros Moschovas
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Sophie Tkebuchava
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Rauf Safarov
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Mahmoud Diab
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Gloria Faerber
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, Am Klinikum 1, 07747, Jena, Germany
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18
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Furukawa N, Gummert JF, Börgermann J. Tailored approach for severe aortic stenosis. J Thorac Cardiovasc Surg 2018; 156:2139. [PMID: 30449574 DOI: 10.1016/j.jtcvs.2018.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 07/13/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Nobuyuki Furukawa
- Clinic of Cardiothoracic Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Jan F Gummert
- Clinic of Cardiothoracic Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Jochen Börgermann
- Clinic of Cardiothoracic Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
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19
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Edelman JJ, Thourani VH. Transcatheter aortic valve replacement and surgical aortic valve replacement: Both excellent therapies. J Thorac Cardiovasc Surg 2018; 156:2135-2137. [PMID: 30449571 DOI: 10.1016/j.jtcvs.2018.07.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 07/21/2018] [Indexed: 11/16/2022]
Affiliation(s)
- J James Edelman
- Department of Cardiac Surgery, MedStar Heart and Vascular Institute, Georgetown University, Washington, DC
| | - Vinod H Thourani
- Department of Cardiac Surgery, MedStar Heart and Vascular Institute, Georgetown University, Washington, DC
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20
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Aortic valve therapies: Different approaches and outcomes. J Thorac Cardiovasc Surg 2018; 156:2135. [PMID: 30449570 DOI: 10.1016/j.jtcvs.2018.06.087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 06/28/2018] [Indexed: 11/23/2022]
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21
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Stonehenge technique is associated with faster aortic clamp time in group of minimally invasive aortic valve replacement via right infra-axillary thoracotomy. Gen Thorac Cardiovasc Surg 2018; 66:700-706. [PMID: 30117124 DOI: 10.1007/s11748-018-0987-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 08/01/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Trans-right axillary aortic valve replacement (TAX-AVR) remains uncommon. We developed a special method to pull the heart closer to the right chest wall to make the surgery as easy and safe as aortic valve replacement via median sternotomy. Because the retraction sutures lifting the ascending aorta and aortic root are arranged circularly around the wound, we named this technique "Stonehenge technique". METHODS We examined 47 patients who underwent aortic valve replacement through a small right infra-axillary thoracotomy as the initial surgical therapy. These patients were divided into two groups: the conventional TAX-AVR group that underwent AVR via the conventional small right axillary incision approach (n = 20) and the TAX-AVR with SH group that underwent AVR with the Stonehenge technique (n = 27). RESULTS The aortic cross-clamp and the extracorporeal circulation time were significantly shorter in the TAX-AVR with SH group than in the conventional TAX-AVR group (conventional TAX-AVR group: 125.5 ± 47.9; TAX-AVR with SH group: 96.0 ± 14.0, p = 0.004, and conventional TAX-AVR group: 163.8 ± 55.9; TAX-AVR with SH group: 140.0 ± 16.8, p = 0.04). CONCLUSION The outcomes of this technique depend on the site of the retraction sutures in the opened pericardium, direction of pull, amount of force applied, and precautions taken. If performed correctly, the ascending aorta and the root can be pulled from the wound to within the surgeon's fingers' reach, thereby reducing aortic cross-clamp and extracorporeal circulation times in group of minimally invasive aortic valve replacement via right infra-axillary thoracotomy.
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All roads lead to Rome… really? J Thorac Cardiovasc Surg 2018; 156:1835-1836. [PMID: 29958661 DOI: 10.1016/j.jtcvs.2018.05.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 05/13/2018] [Accepted: 05/14/2018] [Indexed: 11/21/2022]
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Abstract
Transcatheter aortic valve implantation (TAVI) is currently performed through an alternative access in 15% of patients. The transapical access is progressively being abandoned as a result of its invasiveness and poor outcomes. Existing data does not allow TAVI operators to favour one access over another - between transcarotid, trans-subclavian and transaortic - because all have specific strengths and weaknesses. The percutaneous trans-subclavian access might become the main surgery-free alternative access, although further research is needed regarding its safety. Moreover, the difficult learning curve might compromise its adoption. The transcaval access is at an experimental stage and requires the development of dedicated cavo-aortic crossing techniques and closure devices.
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Affiliation(s)
- Pavel Overtchouk
- Centre Hospitalier Regional et Universitaire de Lille Lille, France
| | - Thomas Modine
- Centre Hospitalier Regional et Universitaire de Lille Lille, France
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