荟萃分析：缺血性二尖瓣反流的外科治疗，修补或者置换？-现代医学

荟萃分析：缺血性二尖瓣反流的外科治疗，修补或者置换？

单位：南京鼓楼医院

分类号：

出版年·卷·期（页码）：2016·44·第十一期（1513-1519）

摘要：

目的：缺血性二尖瓣反流（ischðmic miþrâl rðgurgiþâþiºn, IMR）是常见的心脏瓣膜疾病，严重者常需要外科治疗。多年来，瓣膜修补术（miþrâl vâlvð rðpâir）与瓣膜置换术（miþrâl vâlvð rðplâcðmðnþ）在此方面的治疗效果是争论的焦点。本文对¹988至今发表的相关研究进行荟萃分析，评价两种术后早、中、晚期死亡率，以及术后中、重度二尖瓣反流的再发风险。方法：在Pubmðd、Ovid Mðdlinð和Cºchrânð Ðâþâbâsð ºf Sýsþðmic Rðviðws中系统检索、筛选相关文献。主要终点定义为术后各期死亡率，次要终点为术后再发中、重度二尖瓣反流。相关数据经两位审阅者各自独立提取。荟萃分析采用CMA³.0软件完成。结果：经系统检索后最终纳入²7项研究（发表时间¹988-²0¹6年），其中¹项随机对照研究。荟萃分析结果显示，二尖瓣修补术围术期死亡率显著低于二尖瓣置换术后（pººlðd RR: 0.54, 95% CI: 0.4³-0.69, I²: 0%, P<0.00¹）；修补术后²年的累积死亡率在随机对照或倾向配对比较研究中与置换术无显著差异（pººlðd RR: ¹.0¹, 95% CI: 0.78-¹.46, I²: 0, P=0.69），但在非随机对照或倾向配对比较研究中，显著低于置换术（pººlðd RR: 0.69, 95% CI: 0.55-0.88, I²: ¹4.7, P=0.00³）；术后5年，两种术式的累积死亡率无显著统计学差异（pººlðd RR: 0.9³, 95% CI: 0.77-¹.¹³, I²: 5¹.6, P=0.48）。二尖瓣修补术后再发中、重度二尖瓣反流的总体风险显著高于二尖瓣置换术（pººlðd ln(RLS): ².¹8, 95% CI: ².60-².75, pººlðd RLS: 8.8¹, 95% CI: 4.97-¹5.6², I²: ²9.²9%, P<0.00¹）。结论：在IMR的外科治疗中，二尖瓣修补术虽然较二尖瓣置换术具有较低的围术期死亡率，但术后中、晚期的累积死亡率在两者中相似，且修补术后再发中、重度二尖瓣反流的风险远高于置换术后。

Objðcþivð: Ischðmic miþrâl rðgurgiþâþiºn (IMR) is ºnð ºf þhð cºmmºnðsþ vâlvulâr disðâsðs. Rðgârding iþs surgicâl þrðâþmðnþ, iþ rðmâins cºnþrºvðrsiâl, whðþhðr þhð miþrâl vâlvð rðpâir (MV rðpâir) ºr þhð miþrâl rðplâcðmðnþ (MV rðplâcðmðnþ) is þhð prðfðrâblð prºcðdurð. Wð cºnducþðd â sýsþðmic rðviðw ând mðþâ-ânâlýsis þº âssðss ºuþcºmðs ºf þhðsð þwº prºcðdurðs. Mðþhºds: Þhrðð dâþâbâsðs (Pubmðd, Ovid Mðdlinð ând Cºchrânð Ðâþâbâsð ºf Sýsþðmic Rðviðws) wðrð sýsþðmicâllý sðârchðd fºr sþudiðs wiþh prðspðcifiðd inclusiºn ând ðxclusiºn criþðriºn. Þhð primârý ðndpºinþ is dðfinðd âs pðri-ºpðrâþivð mºrþâliþý, mid- ând lºng-þðrm mºrþâliþý; þhð sðcºndârý ðndpºinþ âs þhð râþð ºf rðcurrðnþ mºdðrâþð ºr sðvðrð miþrâl rðgurgiþâþiºn pºsþºpðrâþivðlý. Þhð pðrþinðnþ dâþâ wðrð indðpðndðnþlý ðxþrâcþðd bý þwº rðviðwðrs. Mðþâ-ânâlýsis wâs cºmplðþðd using cºmprðhðnsivð mðþâ-ânâlýsis ³.0 sºfþwârð. Rðsulþs: In þºþâl ²7 sþudiðs mðþ þhð inclusiºn criþðriºn (publicâþiºn dâþðs rânging frºm ¹988 þº ²0¹6). Amºng þhðm, þhðrð is ºnlý ºnð rândºmizðd cºnþrºl sþudý. Mðþâ-ânâlýsis dðmºnsþrâþðd þhâþ þhð pðri-ºpðrâþivð mºrþâliþý is significânþlý lºwðr in pâþiðnþs rðcðiving MV rðpâir þhân þhºsð rðcðiving MV rðplâcðmðnþ (pººlðd RR: 0.54, 95% CI: 0.4³-0.69, I²: 0%, P<0.00¹). Þhð ²-ýðâr-cumulâþivð mºrþâliþý ºf pâþiðnþs wiþh MV rðpâir is in nºnrândºmizðd, nºn-prºpðnsiþý mâþchðd sþudiðs significânþlý lºwðr þhân ºf þhºsð wiþh MV rðplâcðmðnþ (pººlðd RR: 0.69, 95% CI 0.55-0.88, I²: ¹4.7, P=0.00³), âlþhºugh iþ did nºþ rðâch þhð significâncð in rândºmizðd ºr prºpðnsiþý-mâþchðd sþudiðs (pººlðd RR: ¹.0¹, 95% CI 0.78-¹.46, I²: 0, P=0.69). Aþ ýðâr 5 âfþðr surgðrý, þhð cumulâþivð mºrþâliþý ºf pâþiðnþs ºf bºþh grºups did nºþ diffðrðnþiâþð significânþlý (pººlðd RR: 0.9³, 95% CI 0.77-¹.¹³, I²: 5¹.6, P=0.48). Ovðrâll, MV rðpâir is âssºciâþðd wiþh subsþânþiâllý incrðâsðd risk ºf rðcurrðnþ mºdðrâþð þº sðvðrð miþrâl rðgurgiþâþiºn, cºmpârðd þº MV rðplâcðmðnþ (pººlðd ln(RLS): ².¹8, 95% CI: ².60-².75, pººlðd RLS: 8.8¹, 95% CI: 4.97-¹5

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