ABSTRACT
OBJECTIVES: This study aimed to estimate temporal trends in clinical presentation and short-term outcomes of transcatheter aortic valve replacement (TAVR) with self-expandable prostheses in South America through a systematic review and meta-analysis of observational data. METHODS: We comprehensively searched for articles published in peer-reviewed medical journals and for abstracts presented in medical conferences of the region from September 1, 2008, to June 29, 2020. We included single-center studies on self-expandable TAVR populations with ≥ 10 patients from South America. RESULTS: A total of 28 cohorts from 6 countries pooling 1780 patients were included in a random-effects meta-analysis. Pooled estimates of age changed during time (period 2011-2015, 81.6 years; 95% confidence interval [CI] 80.7-82.4; period 2016-2018, 80.6 years; 95% CI 79.8-81.3; period 2019: 78.5 years; 95% CI 77.0-80.0; P = .0003); no other temporal trends in patient characteristics were ascertained. Temporal trends in short-term mortality pooled estimates were in-hospital mortality (11.8% [95% CI 8.2-16.7] for the period 2011-2015, 6.6% [95% CI 4.5-9.6] for the period 2016-2018, and 4.4% [95% CI 1.9-9.8] for the period 2019 [P = .007]) and 30-day mortality (12.8% [95% CI 7.7-20.4], 9.7% [95% CI 7.0-13.3], and 5.7% [95% CI 2.8-11.3], respectively [P =.044]). These associations between reporting year of the study and lower mortality remained after adjusting by age and surgical risk (multivariate meta-regression). CONCLUSIONS: In studies reported between 2011 and 2019 in South America, we demonstrated a clear time trend toward reduction of short-term mortality after self-expandable TAVR, independently of age and surgical risk of populations. These findings are relevant to the local reassessment of cost-effectiveness of TAVR.
Subject(s)
Aortic Valve Stenosis , Transcatheter Aortic Valve Replacement , Aortic Valve/surgery , Aortic Valve Stenosis/etiology , Aortic Valve Stenosis/surgery , Humans , Observational Studies as Topic , Risk Factors , South AmericaABSTRACT
OBJECTIVES: To estimate in-hospital and 30-day outcomes after transcatheter aortic valve replacement (TAVR) in South America through a systematic review and meta-analysis of observational data. METHODS: We comprehensively searched for papers published in peer-reviewed medical journals and for abstracts presented in medical conferences of the region from 1 September 2008, through 29 June 2020, using predefined criteria. We included single-centre studies on TAVR populations with ≥10 patients from South America reporting any in-hospital or 30-day clinical outcome. RESULTS: Fifty-five cohorts from seven countries, pooling 3001 patients, were included in a random-effects meta-analysis. Self-expandable prostheses were the most frequently implanted. Pooled estimate of procedure success by VARC2 criteria was 90.0% (95%CI 81.8%-94.7%; I2 75.0%). The pooled estimate rates of the outcomes were as follow: post-procedure moderate or severe aortic regurgitation, 9.7% (95%CI 6.0%-15.4%; I2 65.4%), in-hospital cardiac tamponade, 4.0% (95%CI 2.5%-6.6%; I2 0%), in-hospital stroke, 4.1% (95%CI 2.9%-5.7%; I2 0%), in-hospital major vascular complication, 7.8% (95%CI 5.2%-11.5%; I2 22.3%), in-hospital permanent pacemaker implantation, 19.4% (95%CI 15.9%-23.4%; I2 53.8%), in-hospital mortality, 8.0% (95%CI 6.7%-9.6%; I2 0%), and 30-day mortality, 9.7% (95%CI 7.9%-11.8%; I2 26.4%). CONCLUSION: As compared with published international registries, the overall results of TAVR in South America seemed underrated. Significant heterogeneity was observed in procedural success, pacemaker requirement, and post-procedure moderate or severe aortic regurgitation. This study provides a real-life framework for the analysis of the performance of this technology in the region, intended to be a starting point for quality improvement.
Subject(s)
Aortic Valve Stenosis , Stroke , Transcatheter Aortic Valve Replacement , Aortic Valve/surgery , Aortic Valve Stenosis/surgery , Humans , Registries , Risk Factors , Treatment OutcomeABSTRACT
COVID-19 pandemic is challenging Latin American health systems, which could benefit from information to make appropriate decisions in contexts of constrained health resources.Objective: to evaluate, in adult patients with suspected mild clinical forms of COVID-19, the clinical effectiveness (life expectancy) and resource consumption (days of hospitalization) of different management strategies.Methods: stochastic decision tree comparing the conventional strategy recommended by WHO - PAHO (diagnostic test for COVID-19 and hospitalization of patients testing positive) versus two alternative strategies (immediate addition of a prognostic test with hospitalization according to its result, or follow-up with hospitalization only in case of clinical deterioration).Results: the alternative management strategies showed expected clinical utility similar to the conventional strategy in 80 years-old base cases, and slightly lower in 60 years- and 40 years-old base cases, with lower consumption of hospitalization days. In sensitivity analysis, alternative strategies comparatively improved their expected clinical utility given a lower sensitivity of the diagnostic test or a higher ability of the follow-up to detect clinical worsening.Conclusions: in cases of suspected COVID-19 without pneumonic infiltrate or signs of severity, alternative strategies can be considered to avoid hospitalization for the majority of patients, especially if efficient follow-up modalities can be implemented. This information is valuable for health decision-makers, to carefully weight clinical and epidemiological elements and design locally feasible strategies.
La pandemia COVID-19 desafía los sistemas de salud de Latinoamérica, que podrían beneficiarse de información para tomar decisiones apropiadas, en contextos de escasez de recursos sanitarios.Objetivo: evaluar, en pacientes adultos con sospecha de formas clínicas leves de COVID-19, la efectividad clínica (expectativa de vida) y el consumo de recursos (días de hospitalización) de distintas estrategias de manejo. Métodos: árbol de decisión estocástico, comparando la estrategia convencional recomendada por OMS - OPS (prueba diagnóstica para COVID-19 y hospitalización ante resultado positivo) versus dos estrategias alternativas (agregado inmediato de una prueba pronóstica con hospitalización según ese resultado, y seguimiento con hospitalización sólo ante empeoramiento clínico). Resultados: las estrategias de manejo alternativas mostraron utilidad clínica esperada similar a la estrategia convencional en casos base de 80 años de edad, y ligeramente inferior en casos base de 60 años y 40 años de edad, con menor consumo de días de hospitalización. En el análisis de sensibilidad, las estrategias alternativas mejoraron comparativamente su utilidad clínica esperada si la sensibilidad de la prueba diagnóstica fuera menor o la capacidad del seguimiento para detectar empeoramiento clínico fuera mayor. Conclusiones: ante casos sospechosos de COVID-19 sin infiltrado neumónico ni signos de gravedad, pueden considerarse estrategias que eviten la hospitalización de la mayoría de los pacientes, en especial si pueden implementarse modalidades de seguimiento eficientes. Esta información es valiosa para los decisores en salud, para analizar ponderadamente elementos clínicos y epidemiológicos y diseñar estrategias factibles localmente.
