不同路径行经导管主动脉瓣置入术围手术期常见并发症的meta分析

目的 系统评价不同路径经导管主动脉瓣置入术(TAVI)围手术期常见并发症的发生情况.方法 通过对PubMed、Embase、Ovid Medline数据库和效果评价文摘数据库(DARE)进行文献检索,获得已公开发表的行经心尖(TAp)、经股动脉(TF)及经升主动脉(TAo)3种路径TAVI的随机对照研究,统计各路径患者术后早期(30 d内)病死率、人工瓣膜瓣周漏、严重出血事件、大血管并发症、卒中、急性肾损伤及起搏器依赖型传导阻滞等手术相关或常见的严重并发症的发生情况,用Review Manager 5.3软件行meta分析.结果 研究共纳入22篇文献,总病例数11 530例.TAp组、TAo组患者术后早期人工瓣膜瓣周漏发生率均低于TF组4.6％(63/1 384) vs 9.2％(400/4 366),P＜0.000 01;6.4％(33/518) vs 9.3％(331/3 541),P=0.002],而术后早期病死率均高于TF组10.0％(271/2 711) vs4.8％ (326/6 756),P＜0.000 01;8.9％(46/518) vs 4.5％(160/3 541),P=0.002].TAp组、TAo组患者的术后早期严重出血发生率均高于TF组8.4％(186/2 204) vs 3.9％(268/6 818),P＜0.000 01;6.5％(35/542) vs 1.4％(50/3 569),P=0.01].TAp组患者术后早期大血管并发症发生率低于TF组2.3％(58/2 524) vs 6.5％(417/6 367),P＜0.000 01],而TAo组与TAp组、TF组相比差异均无统计学意义.3组患者的术后早期卒中发生率差异均无统计学意义(P＞0.05).TF组患者术后早期急性肾损伤发生率低于TAp组8.3％(610/7 334) vs 22.8％(615/2 699),P＜0.000 01]和TAo组3.1％(110/3 569) vs 12.5％(68/542),P＜0.000 01].TF组患者术后早期起搏器依赖型传导阻滞发生率高于TAo组13.2％(472/3 569) vs 9.2％(50/542),P=0.003].结论 经TAp路径及经TF路径行TAVI路径较短,可以有效减少瓣周漏及大血管损伤的发生,具备独特的优势与潜在价值.

Comparison of common peri-operative complications in transcatheter aortic valve implantation through different approaches:a meta-analysis

Objective To systemically evaluate the occurrence of common peri-operative complications in transcatheter aortic valve implantation (TAVI) through different approaches. Methods We searched the database, including PubMed, Embase, Ovid Medline and Database of Abstracts of Review of Effectiveness (DARE) and selected the published randomized controlled studies on the TAVI through the transapical (TAp group) or transfemoral (TF group) or transaortic (TAo group) approaches. And we compared and analyzed the 30-day post-operative mortality and the incidences of early paravalvular leakage (PVL), severe hemorrhage, major vascular complications, stroke, acute kidney injury (AKI) and permanent pacemaker (PPM) required atrioventricular block (AVB). A meta-analysis was carried out by Review Manager 5.3 software. Results A total of 22 studies, 11 530 cases were included in this study. Compared with the TF group, the incidence of early PVL in the TAp and TAo groups was significantly lower (4.6%63/1 384] vs 9.2%400/4 366], P<0.000 01; 6.4%33/518] vs 9.3%331/3 541], P=0.002), while the 30-day post-operative mortality was significantly higher (10.0%271/2 711] vs 4.8%326/6 756], P<0.000 01; 8.9%46/518] vs 4.5%160/3 541], P=0.002). The incidence of severe hemorrhage in the TAp and TAo groups was significantly higher than that in the TF group (8.4%186/2 204] vs 3.9%268/6 818], P<0.000 01; 6.5%35/542] vs 1.4%50/3 569], P=0.01). The major vascular complication had a lower incidence in the TAp group compared with the TF group (2.3%58/2 524] vs 6.5%417/6 367], P<0.000 01). There was no difference in the occurrence of stroke among the three groups (P>0.05). TF group showed a significant reduction of AKI incidence compared with the TAp group (8.3%610/7 334] vs 22.8%615/2 699], P<0.000 01) and the TAo group (3.1%110/3 569] vs 12.5%68/542], P<0.000 01). TF group showed a significant increase in the incidence of PPM required AVB compared with the TAo group (13.2%472/3 569] vs 9.2%50/542], P=0.003). Conclusion The TAp and TF approaches have a shorter path in TAVI and can significantly reduce the occurance of PVL and major vascular impairment, which is an unique advantage and has potential value.