Kuan-Yu Chi1, Ming-Hsiu Chiang2, Yi-No Kang3, Shao-Jung Li4, Yueh-Tsung Chan5, Yang-Ching Chen6, Sen-Te Wang7. 1. Department of Education, Center for Evidence-Based Medicine, Taipei Medical University Hospital, Taipei, Taiwan. 2. School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. 3. Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Institute of Health Policy & Management, College of Public Health, National Taiwan University, Taipei, Taiwan. 4. Cardiovascular Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan; Division of Cardiovascular Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan. 5. Department of General Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan. 6. Department of Family Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Department of Family Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei, Taiwan; Graduate Institute of Metabolism and Obesity Sciences, Taipei Medical University, Taipei, Taiwan. 7. Department of Family Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Department of Family Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Health Management Center, Taipei Medical University Hospital, Taipei, Taiwan. Electronic address: wangader@tmu.edu.tw.
Abstract
OBJECTIVE: The optimal selection of prosthetic heart valve for dialysis-dependent patients remains controversial. We investigated the comparative effectiveness and safety of mechanical prosthesis (MP) and bioprosthesis (BP) for these patients. METHODS: After the systematic review, we included studies that involved patients on dialysis undergoing aortic valve replacement or mitral valve replacement (MVR) and reported comparative outcomes of MP and BP. Meta-analysis was performed using random-effects model. We conducted a subgroup analysis based on the valve position and postoperative international normalized ratio (INR), which was extracted from either tables or methods of each study. A meta-regression was used to examine the effects of study-level covariates. RESULTS: We included 24 retrospective studies without randomized-controlled trials, involving 10,164 participants (MP = 6934, BP = 3230). Patients undergoing aortic valve replacement with MP exhibited a better long-term survival effectiveness (hazard ratio, 0.64; 95% confidence interval [CI], 0.47-0.86). Conversely, studies including MVR demonstrated little difference in survival (hazard ratio, 0.90; 95% CI, 0.73-1.12). A meta-regression revealed that age had little effect on long-term survival difference between MP and BP (β = -0.0135, P = .433). MP had a significantly greater bleeding risk than did BP when INR was above 2.5 (incidence rate ratio, 10.58; 95% CI, 2.02-55.41). However, when INR was below 2.5, bleeding events were comparable (incidence rate ratio, 1.73; 95% CI, 0.78-3.82). The structural valve deterioration rate was significantly lower in MP (risk ratio, 0.24; 95% CI, 0.14-0.44). CONCLUSIONS: MP is a reasonable choice for dialysis-dependent patients without additional thromboembolic risk requiring aortic valve replacement, for its better long-term survival, durability, and noninferior bleeding risk compared with BP. Conversely, BP might be an appropriate selection for patients with MVR, given its similar survival rate and lower bleeding risk. Although our meta-regression demonstrates little influence of age on long-term survival difference between MP and BP, further studies stratifying patients based on age cut-off are mandatory.
OBJECTIVE: The optimal selection of prosthetic heart valve for dialysis-dependent patients remains controversial. We investigated the comparative effectiveness and safety of mechanical prosthesis (MP) and bioprosthesis (BP) for these patients. METHODS: After the systematic review, we included studies that involved patients on dialysis undergoing aortic valve replacement or mitral valve replacement (MVR) and reported comparative outcomes of MP and BP. Meta-analysis was performed using random-effects model. We conducted a subgroup analysis based on the valve position and postoperative international normalized ratio (INR), which was extracted from either tables or methods of each study. A meta-regression was used to examine the effects of study-level covariates. RESULTS: We included 24 retrospective studies without randomized-controlled trials, involving 10,164 participants (MP = 6934, BP = 3230). Patients undergoing aortic valve replacement with MP exhibited a better long-term survival effectiveness (hazard ratio, 0.64; 95% confidence interval [CI], 0.47-0.86). Conversely, studies including MVR demonstrated little difference in survival (hazard ratio, 0.90; 95% CI, 0.73-1.12). A meta-regression revealed that age had little effect on long-term survival difference between MP and BP (β = -0.0135, P = .433). MP had a significantly greater bleeding risk than did BP when INR was above 2.5 (incidence rate ratio, 10.58; 95% CI, 2.02-55.41). However, when INR was below 2.5, bleeding events were comparable (incidence rate ratio, 1.73; 95% CI, 0.78-3.82). The structural valve deterioration rate was significantly lower in MP (risk ratio, 0.24; 95% CI, 0.14-0.44). CONCLUSIONS: MP is a reasonable choice for dialysis-dependent patients without additional thromboembolic risk requiring aortic valve replacement, for its better long-term survival, durability, and noninferior bleeding risk compared with BP. Conversely, BP might be an appropriate selection for patients with MVR, given its similar survival rate and lower bleeding risk. Although our meta-regression demonstrates little influence of age on long-term survival difference between MP and BP, further studies stratifying patients based on age cut-off are mandatory.
Authors: Kevin S Kim; Emilie P Belley-Côté; Saurabh Gupta; Arjun Pandey; Ali Alsagheir; Ahmad Makhdoum; Graham McClure; Brooke Newsome; Sophie W Gao; Matthias Bossard; Tetsuya Isayama; Yasuhisa Ikuta; Michael Walsh; Amit X Garg; Gordon H Guyatt; Richard P Whitlock Journal: Can J Surg Date: 2022-07-12 Impact factor: 2.840