Meta-Analysis of Mitral Valve Repair Versus Replacement for Rheumatic Mitral Valve Disease.

BACKGROUND: Rheumatic heart disease remains one of the leading causes of heart valve disease worldwide despite being a preventable condition. Mitral valve repair is superior to replacement in severe degenerative mitral valve disease, however its role in rheumatic valve disease remains controversial. This meta-analysis compared mitral valve repair and replacement in rheumatic heart disease. METHODS: Medline, EMBASE, Cochrane and Scopus were searched from January 1980 to June 2016 for original studies reporting outcomes of both mitral valve repair and replacement in rheumatic heart disease in adults, children or both. Two (2) authors independently assessed studies for inclusion, followed by data extraction and analysis. RESULTS: The search yielded 930 articles, with 98 full-texts reviewed after initial screening and 13 studies subsequently included for analysis, totalling 2,410 mitral valve repairs and 3,598 replacements. Pooled rates and odds ratio (95% confidence interval) for operative mortality of repair versus replacement was 3.2% versus 4.3%, 0.68 (0.50-0.92; p=0.01). Pooled odds ratios (95% confidence interval) were for long-term mortality 0.41 (0.30-0.56; p<0.001); reoperation 3.02 (1.72-5.31; p<0.001); and bleeding 0.26 (0.11-0.63; p=0.003). There was a trend towards lower thrombo-embolism 0.42 (0.17-1.03; p=0.06), and no significant difference in endocarditis (p=0.76), during follow-up. CONCLUSION: Mitral valve repair is associated with reduction in operative and long-term mortality and bleeding, so is recommended in rheumatic mitral valve disease where feasible, but it does entail a higher rate of reoperation during follow-up.

Catheter vs thoracoscopic ablation for atrial fibrillation: Meta-analysis of randomized trials.

BACKGROUND: We meta-analyzed the efficacy and safety of catheter (CA) vs thoracoscopic (TA) ablation for atrial fibrillation (AF). METHODS: PubMed, Embase, and Cochrane databases were searched until 31/12/2019 for relevant randomized trials and subsequent pooled analyses. RESULTS: In six trials totaling 465 patients (254 CA/211 TA), 1-year AF recurrences were higher for CA (46% vs 26%, odds ratio 2.90 [95% CI 1.32-6.38]), whereas total adverse events were lower (10% vs 25%, 0.35 [0.14-0.86], respectively). CONCLUSION: CA has lower efficacy but higher safety than TA. CA should remain the first-line AF ablation strategy, and TA reserved for selected CA-resistant patients where rhythm control is clinically necessary.

Meta-Analysis of Bleeding Scores Performance for Acute Coronary Syndrome.

BACKGROUND: Bleeding is a common and frequently devastating complication in acute coronary syndrome (ACS). It is critical to evaluate in the current era of ACS management involving invasive strategies and potent anti-thrombotics. Risk models remain under-utilised in this setting but may guide the choice and duration of therapy. We compared their performances for predicting bleeding in ACS patients in this meta-analysis. METHODS: Medline, EMBASE, Cochrane and Scopus were searched for relevant articles from 1980 to 31 December 2017 assessing external validation of risk scores for bleeding after ACS. Two (2) authors independently reviewed the searched studies for eligibility, followed by pooled analyses using random effects models. RESULTS: Amongst 1,843 articles searched, 73 full-texts were reviewed and 17 studies totalling 18,155 patients were included for analysis. C-statistics (95% confidence interval) for predicting in-hospital major bleeding by risk model were Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) 0.714 (0.659-0.779), Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) 0.711 (0.626-0.797), Acute Coronary Treatment and Intervention Outcomes Network (ACTION) 0.767 (0.737-0.797), Global Registry of Acute Coronary Events (GRACE) 0.689 (0.473-0.905) and HAS-BLED 0.636 (0.460-0.812). CRUSADE also predicted bleeding during medium-term follow-up c=0.704 (0.644-0.765). It performed better for radial versus femoral access (c=0.826 and 0.734), invasive versus non-invasive strategy (c=0.752 and 0.625) and similarly for ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI) (c=0.791 and 0.760). Heterogeneities of studies and paucity of studies assessing risk scores beyond CRUSADE were important limitations. CONCLUSIONS: Acute coronary syndrome-specific bleeding scores had moderate discrimination for bleeding, while the GRACE and HAS-BLED scores could not. The ACTION score had the highest pooled c-statistic, while the CRUSADE score was the most widely studied, and also performed better for invasive strategy and radial access subgroups.

Comparison of percutaneous MitraClip versus mitral valve surgery for severe mitral regurgitation: a meta-analysis: Mitraclip and mitral valve surgery meta-analysis.

AIMS: Mitral valve surgery (MVS) is the gold-standard treatment for severe symptomatic mitral regurgitation. Percutaneous mitral valve interventions such as the MitraClip procedure offer another dimension to its management particularly in high-risk patients. We meta-analysed the outcomes of MitraClip and MVS. METHODS AND RESULTS: PubMed, MEDLINE, Embase, Cochrane and Scopus from 1980/01-2019/06 were searched for eligible studies. Data were extracted and pooled using random-effects models. After screening 959 studies and reviewing 21 full-text articles, nine studies totalling 640 MitraClip and 531 MVS (91% valve repair) procedures were included in the meta-analysis. MitraClip patients were older, with a higher prevalence of previous cardiac surgery, coronary disease and a higher EuroSCORE (all p<0.05) than MVS patients. Pooled operative mortality was similar for MitraClip, 3%, versus MVS, 5%, odds ratio (OR): 0.58, 95%, CI: 0.28-1.19, as well as at 1 year mortality, OR: 1.09, CI: 0.71-1.68 and 3-year mortality, OR: 1.08, CI: 0.72-0.163. MitraClip patients had higher rates of early and late significant mitral regurgitation (MR) and more cardiovascular readmissions, while MVS had higher rates of in-hospital bleeding and pacemaker implantation (all p<0.05). CONCLUSIONS: MitraClip patients had a higher baseline risk than MVS, but there were no significant differences in short- and long-term mortality. MitraClip patients had higher rates of cardiovascular admissions and significant MR post-operatively, while MVS patients had more procedural complications.

Meta-analysis of ultrasound-guided vs conventional vascular access for cardiac electrophysiology procedures.

BACKGROUND: Vascular complications are common during invasive cardiac electrophysiology procedures. This meta-analysis compares outcomes following ultrasound and nonultrasound-guided vascular access for these procedures. METHODS: PubMed, Embase and Cochrane 01/01/1980-30/09/2018 were searched for relevant studies to meta-analyse. RESULTS: Seven studies (6269 patients) were included. Pooled rates and odds ratio(95% confidence interval) for ultrasound and nonultrasound subgroups were 1.2% vs 3.0%, 0.32 (0.21-0.49) for all vascular complications, with less hematomas and arterial punctures but similar arteriovenous fistulas, pseudoaneurysms or retroperitoneal bleeds. CONCLUSION: Ultrasound guidance had less complications due to less hematoma and arterial puncture, and is generally recommended for electrophysiology procedures.

Patent Foramen Ovale Closure Versus Medical Therapy for Cryptogenic Stroke: Meta-Analysis of Randomised Trials.

BACKGROUND: Patent foramen ovale (PFO) is a common anatomic variant associated with cryptogenic stroke. Percutaneous PFO closure in these patients to prevent recurrent neurological events has been controversial for decades, and mixed results have been reported from past and recent observational and randomised studies. This meta-analysis of randomised trials aims to compare the efficacy and safety of PFO closure with medical therapy for cryptogenic stroke patients. METHODS: Medline, PubMed, EMBASE, Scopus and Cochrane were searched from January 1980 to September 2017 by two authors independently to include original randomised trials comparing PFO closure with medical therapy for secondary stroke prevention. Relevant study and baseline characteristics and outcomes were extracted and pooled using random-effects models. RESULTS: Amongst 619 articles searched giving 10 full-texts assessed, six studies reporting five randomised trials and totalling 1,829 PFO closure and 1,611 medical therapy patients were included. Pooled hazards ratios (95% confidence interval, p-value) ischaemic stroke, transient ischaemic attack (TIA) and composite neurovascular or mortality events were 0.41 (0.19-0.90, p=0.03), 0.77 (0.51-1.14, p=0.19) and 0.60 (0.44-0.81, p<0.001) for PFO closure compared to medical therapy. Any adverse events, major bleeding and all-cause mortality were similar between modalities (p=0.37-0.95), however PFO closure had higher rates of new onset atrial fibrillation at 4.6 times (p<0.001). CONCLUSION: Our meta-analysis found that, in patients with cryptogenic stroke, percutaneous PFO closure is beneficial at reducing ischaemic stroke and composite neurovascular or mortality events, with a higher incidence of new atrial fibrillation, compared to medical therapy.

Performance of contemporary surgical risk scores for transcatheter aortic valve implantation: A meta-analysis.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is considered for severe aortic valve disease at high and now intermediate risk for surgical aortic valve replacement. Risk stratification plays a critical role decision-making for intervention and modality. We compared the prognostic utility of surgical risk scores for TAVI in this meta-analysis. METHODS: MEDLINE, Embase, Cochrane and Web of Science databases from 1 January 1980 to 31 December 2015 were searched. Studies were systematically reviewed for inclusion, and data extracted for pooled analyses. RESULTS: Amongst 1688 articles searched, 47 full-text articles were screened and 24 studies (12,346 TAVI cases) included for analyses. Pooled c-statistics (95% confidence interval) for operative mortality were EuroSCORE 0.62 (0.57-0.67), EuroSCORE II 0.62 (0.59-0.66), STS Score 0.62 (0.59-0.65). Pooled calibration odds ratios (95%CI) were EuroSCORE 0.31 (0.25-0.38), EuroSCORE II 1.26 (1.06-1.51), STS 0.95 (0.72-1.27). C-statistics (95%CI) for 1-year mortality were EuroSCORE 0.62 (0.57-0.67), EuroSCORE II 0.66 (0.61-0.71) and STS Score 0.58 (0.53-0.64). CONCLUSION: Surgical risk scores at most modestly discriminated operative and 1-year mortality. The EuroSCORE grossly over-estimated operative mortality while the EuroSCORE II and STS Scores fitted better to TAVI outcomes with their own limitations. There is a need for the development and validation of TAVI-specific risk models.