Systematic Review

Mechanical Versus Bioprosthetic Aortic Valve Replacement in Middle-Aged Adults: A Systematic Review and Meta-Analysis

by

Zhao DF, Seco M, Wu JJ, Edelman JB, Wilson MK, Vallely MP, Byrom MJ, Bannon PG

Ann. Thorac. Surg. 2016 Jan;

PMID: 26794881

Abstract

The choice of a bioprosthetic valve (BV) or mechanical valve (MV) in middle-aged adults undergoing aortic valve replacement is a complex decision that must account for numerous prosthesis and patient factors. A systematic review and meta-analysis was performed to compare long-term survival, major adverse prosthesis-related events, anticoagulant-related events, major bleeding, reoperation, and structural valve degeneration in middle-aged patients receiving a BV or MV. A comprehensive search from six electronic databases was performed from their inception to February 2016. Results from patients aged less than 70 years undergoing aortic valve replacement with a BV or MV were included. There were 12 studies involving 8,661 patients. Baseline characteristics were similar. There was no significant difference in long-term survival among patients aged 50 to 70 or 60 to 70 years. Compared with MVs, BVs had significantly fewer long-term anticoagulant-related events (hazard ratio [HR] 0.54, p = 0.006) and bleeding (HR 0.48, p < 0.00001) but significantly greater major adverse prosthesis-related events (HR 1.82, p = 0.02), including reoperation (HR 2.19, p < 0.00001). The present meta-analysis found no significant difference in survival between BVs and MVs in patients aged 50 to 70 or 60 to 70 years. Compared with MVs, BVs have reduced risk of major bleeding and anticoagulant-related events but increased risk of structural valve degeneration and reoperation. However, the mortality consequences of reoperation appear lower than that of major bleeding, and recent advances may further lower the reoperation rate for BV. Therefore, this review supports the current trend of using BVs in patients more than 60 years of age.

Equivalent outcomes after coronary artery bypass graft surgery performed by consultant versus trainee surgeons: A systematic review and meta-analysis

by

Virk SA, Bowman SR, Chan L, Bannon PG, Aty W, French BG, Saxena A

J. Thorac. Cardiovasc. Surg. 2016 Mar;151(3):647-654.e1

PMID: 26707761

Abstract

OBJECTIVE: In recent years, concerns have been raised about the learning opportunities available to cardiac surgical trainees. This meta-analysis was conducted to assess the impact of trainee operator status on clinical outcomes after coronary artery bypass graft (CABG) surgery.

METHODS: Medline, EMBASE, and the Cochrane Library were systematically searched for studies that reported CABG outcomes according to the training status of the primary operator (consultant vs trainee). Data were independently extracted by 2 investigators; a meta-analysis was conducted according to predefined clinical endpoints.

RESULTS: Sixteen observational studies (n = 52,966) met criteria for inclusion, with 8 studies (n = 36,479) reporting propensity-adjusted analyses. Trainee cases were associated with increased aortic crossclamp duration (mean difference: 4.80; 95% confidence interval [CI], 0.76-8.83) and cardiopulmonary bypass duration (mean difference: 4.24; 95% CI, 0.00-8.47). Perioperative mortality was similar for CABG performed primarily by trainees versus consultants (odds ratio 0.98; 95% CI, 0.81-1.18). No significant difference was found in the incidence of perioperative stroke, myocardial infarction, acute renal failure, reoperation for bleeding, or wound infection. Trainee operator status was not associated with increased midterm mortality (hazard ratio 1.00; 95% CI, 0.90-1.11). In subgroup analysis that included 5 studies and 8025 patients, off-pump CABG trainee cases were not associated with increased perioperative mortality or morbidity.

CONCLUSIONS: With appropriate supervision, conventional CABG can be performed by trainee surgeons without an adverse impact on perioperative outcomes or midterm survival. Data regarding off-pump CABG are limited, and further research is warranted to ascertain the impact of trainee operator status on long-term outcomes after off-pump CABG.

The Freestyle Aortic Bioprosthesis: A Systematic Review

by

Sherrah AG, Edelman JJ, Thomas SR, Brady PW, Wilson MK, Jeremy RW, Bannon PG, Vallely MP

Heart Lung Circ 2014 Dec;23(12):1110-1117

PMID: 25047283

Abstract

BACKGROUND: The Medtronic Freestyle bioprosthesis (FSB) provides an alternative to other prostheses for both aortic valve and aortic root surgery. This paper is a systematic review of the post-operative outcomes in patients with aortic valve and/or aortic root disease following FSB implantation.

METHODS: Electronic databases were searched for primary analysis, prospective randomised studies comparing the FSB with an alternative aortic prosthesis were included. Additionally, case series that included data for at least 100 individual operated patients were used for secondary analysis.

RESULTS: Among three identified randomised studies, 199 FSB cases were compared with homografts, and stented and an alternative stentless bioprosthesis. The FSB showed comparable hospital mortality (4.5% vs 5.3%) and eight-year actuarial survival (80±5.0% versus 77±6.0%) with the homograft (respectively) and comparable reduction in left ventricular mass index relative to other prosthesis types. Over 6000 individual patients were included in the selected 15 case series. Weighted mean operative mortality, neurological event rate and five-year actuarial survival was 5.2%, 5.5% and 77.8%, respectively.

CONCLUSION: The FSB performed comparably against alternative prostheses regarding in-hospital mortality, long-term survival and reduction in left ventricular mass index. Included case series demonstrated robust post-operative outcomes in both the short and long term.

Should clopidogrel be discontinued before coronary artery bypass grafting for patients with acute coronary syndrome? A systematic review and meta-analysis

by

Cao C, Indraratna P, Ang SC, Manganas C, Park J, Bannon PG, Yan TD

J. Thorac. Cardiovasc. Surg. 2014 Dec;148(6):3092-8

PMID: 24954178

Abstract

OBJECTIVE: Patients presenting with acute coronary syndrome (ACS) are treated with dual antiplatelet agents, including aspirin and clopidogrel, to prevent mortality and recurrent ischemia. However, those who require coronary artery bypass grafting (CABG) could have increased postoperative bleeding and bleeding-related adverse outcomes. The current guidelines on clinical management differ significantly. The present meta-analysis examined the evidence for clopidogrel in the treatment of patients presenting with ACS requiring CABG, with a focus on the timing of medication cessation before surgery.

METHODS: A systematic review of 9 electronic databases was performed to identify all relevant studies with comparable outcomes for patients with ACS treated with clopidogrel before CABG. The endpoints included reoperation, major bleeding, mortality, and a composite endpoint of mortality and recurrent myocardial infarction.

RESULTS: Five relevant studies were identified according to the predefined selection criteria. Patients who had received clopidogrel had a significantly lower incidence of composite endpoints than those who had not. However, patients who underwent CABG < 5 days after the last dose of clopidogrel had a significantly greater incidence of reoperation, major bleeding, and combined adverse outcomes than those who had had a washout period >5 days.

CONCLUSIONS: The results from the present meta-analysis suggest that patients who present with ACS should be treated with dual antiplatelet therapy, including clopidogrel. However, for patients subsequently referred for CABG, a minimum washout period of 5 days should be observed to minimize perioperative bleeding and bleeding-related complications, unless emergency indications exist. These results differ from those of previous studies and guidelines.

A meta-analysis of endoscopic versus conventional open radial artery harvesting for coronary artery bypass graft surgery

by

Cao C, Tian DH, Ang SC, Peeceeyen S, Allan J, Fu B, Yan TD

Innovations (Phila) 2014 Jul-Aug;9(4):269-75

PMID: 25084252

Abstract

OBJECTIVE: The radial artery has been demonstrated to provide superior long-term patency outcomes compared with saphenous veins for selected patients who undergo coronary artery bypass graft surgery. Recently, endoscopic radial artery harvesting has been popularized to improve cosmetic and perioperative outcomes. However, concerns have been raised regarding the effects on long-term survival and graft patency of this relatively novel technique. The present meta-analysis aimed to assess the safety and the efficacy of endoscopic radial artery harvesting versus the conventional open approach.

METHODS: A systematic review of the current literature was performed on five electronic databases. All comparative studies on endoscopic versus open radial artery harvesting were included for analysis. Primary endpoints included mortality and recurrent myocardial infarction. Secondary endpoints included graft patency, wound infection, hematoma formation, and paresthesia.

RESULTS: Twelve studies involving 3314 patients were included for meta-analysis according to predefined selection criteria. There were no statistically significant differences in overall mortality, recurrent myocardial infarction, or graft patency between the two surgical techniques. However, patients who underwent endoscopic harvesting were found to have significantly lower incidences of wound infection, hematoma formation, and paresthesia.

CONCLUSIONS: Current literature on endoscopic harvesting of the radial artery for coronary artery bypass graft surgery is limited by relatively short follow-up periods as well as differences in patient selection and surgical techniques. In addition, there are currently no randomized controlled trials to provide robust clinical data. However, the available evidence suggests that the endoscopic approach is associated with superior perioperative outcomes without clear evidence demonstrating compromised patency or survival outcomes.

Systematic review of the cost-effectiveness of transcatheter aortic valve implantation

by

Indraratna P, Ang SC, Gada H, Yan TD, Manganas C, Bannon P, Cao C

J. Thorac. Cardiovasc. Surg. 2014 Aug;148(2):509-14

PMID: 24280719

Abstract

OBJECTIVE: Transcatheter aortic valve implantation (TAVI) has emerged as an alternative treatment to aortic valve replacement (AVR) for selected patients with severe aortic stenosis. The present systematic review was conducted to analyze the cost-effectiveness of this novel technique within reimbursed healthcare systems.

METHODS: Two reviewers used 7 electronic databases from January 2000 to November 2012 to identify relevant cost-effectiveness studies of TAVI versus AVR or medical therapy. The primary endpoints were the incremental cost-effectiveness ratio (ICER) and the probability of cost-effectiveness. The eligible studies for the present systematic review included those in which the cost-effectiveness data were measured or projected for TAVI and either medical therapy or AVR. All forms of TAVI were included, and all retrieved publications were limited to the English language.

RESULTS: Eight studies were included for quantitative assessment. The ICER for TAVI compared with medical therapy for surgically inoperable patients ranged from US$26,302 to US$61,889 per quality-adjusted life year gained. The probability of TAVI being cost-effective compared with medical therapy ranged from 0.03 to 1.00. The ICER values for TAVI compared with AVR for high-risk surgical candidates ranged from US$32,000 to US$975,697 per quality-adjusted life year gained. The probability of TAVI being cost-effective in this cohort ranged from 0.116 to 0.709.

CONCLUSIONS: Depending on the ICER threshold selected, TAVI is potentially justified on both medical and economic grounds compared with medical therapy for patients deemed to be surgically inoperable. However, in the high-risk surgical patient cohort, the evidence is currently insufficient to economically justify the use of TAVI in preference to AVR.

A systematic review and meta-analysis of surgical treatments for malignant pleural mesothelioma

by

Cao C, Tian D, Park J, Allan J, Pataky KA, Yan TD

Lung Cancer 2014 Feb;83(2):240-5

PMID: 24360321

Abstract

BACKGROUND: Malignant pleural mesothelioma (MPM) is an aggressive disease of the pleural lining with a dismal prognosis. Surgical treatments of MPM with a curative intent include extrapleural pneumonectomy and extended pleurectomy/decortication (P/D). This meta-analysis aimed to compare the perioperative and long-term outcomes of EPP and extended P/D for selected surgical candidates.

METHODS: A systematic review of the literature was performed on six electronic databases to identify all relevant data on comparative outcomes of extended P/D and EPP in a multimodality setting. Endpoints included perioperative mortality and morbidity, as well as long-term overall survival.

RESULTS: Seven relevant studies with comparative data on EPP (n=632) versus extended P/D (n=513) were identified from the current literature. Comparison of these two groups demonstrated significantly lower perioperative mortality (2.9% vs. 6.8%, p=0.02) and morbidity (27.9% vs. 62.0%, p<0.0001) for patients who underwent extended P/D compared to EPP. Median overall survival ranged between 13-29 months for extended P/D and 12-22 months for EPP, with a trend favouring extended P/D.

CONCLUSIONS: Although it must be emphasized that patient selection and treatment strategies differ between EPP and extended P/D, a number of comparative studies have recently been conducted to compare these two surgical techniques for patients with resectable MPM. The present study indicated that selected patients who underwent extended P/D had lower perioperative morbidity and mortality with similar, if not superior, long-term survival compared to EPP, in the context of multi-modality therapy. This may represent an important paradigm shift in the surgical management of MPM.

Systematic review of robotic minimally invasive mitral valve surgery

by

Seco M, Cao C, Modi P, Bannon PG, Wilson MK, Vallely MP, Phan K, Misfeld M, Mohr F, Yan TD

Ann Cardiothorac Surg 2013 Nov;2(6):704-16

PMID: 24349971

Abstract

BACKGROUND: Robotic telemanipulators have evolved to assist the challenges of minimally invasive mitral valve surgery (MVS). A systematic review was performed to provide a synopsis of the literature, focusing on clinical outcomes and cost-effectiveness.

METHOD: Structured searches of MEDLINE, Embase, and Cochrane databases were performed in August 2013. All original studies except case-reports were included in qualitative review. Studies with ≥50 patients were presented quantitatively.

RESULTS: After applying inclusion and exclusion criteria to the search results, 27 studies were included in qualitative review, 16 of which had ≥50 patients. All studies were observational in nature, and thus the quality of evidence was rated low to medium. Patients generally had good left ventricular performance, were relatively asymptomatic, and mean patient age ranged from 52.6-58.4 years. Rates of intraoperative outcomes ranged from: 0.0-9.1% for conversion to non-robotic surgery, 106±22 to 188.5±53.8 min for cardiopulmonary bypass (CPB) time and 79±16 to 140±40 min for cross-clamp (XC) time. Rates of short-term postoperative outcomes ranged from: 0.0-3.0% for mortality, 0.0-3.2% for myocardial infarction (MI), 0.0-3.0% for permanent stroke, 1.6-15% for pleural effusion, 0.0-5.0% for reoperations for bleeding, 0.0-0.3% for infection, and 1.1-6% for prolonged ventilation (>48 hours), 1.5-5.4% for early repair failure, 12.3±6.7 to 36.6±24.7 hours for intensive care length of stay, 3.1±0.3 to 6.3±3.9 days for hospital length of stay (HLOS) and 81.7-97.6% had no or trivial mitral regurgitation (MR) before discharge.

CONCLUSIONS: All subtypes of mitral valve prolapse are repairable with robotic techniques. CPB and XC times are long, and novel techniques such as the Cor-Knot, Nitinol clips or running sutures may reduce the time required. The overall rates of early postoperative mortality and morbidity are low. Improvements in postoperative quality of life (QoL) and expeditious return to work offset the increase in equipment and intraoperative cost. Evidence for long-term outcomes is as yet limited.

Custodiol for myocardial protection and preservation: a systematic review

by

Edelman JJ, Seco M, Dunne B, Matzelle SJ, Murphy M, Joshi P, Yan TD, Wilson MK, Bannon PG, Vallely MP, Passage J

Ann Cardiothorac Surg 2013 Nov;2(6):717-28

PMID: 24349972

Abstract

INTRODUCTION: Custodiol cardioplegia is attractive for minimally invasive cardiac surgery, as a single dose provides a long period of myocardial protection. Despite widespread use in Europe, there is little data confirming its efficacy compared with conventional (blood or crystalloid) cardioplegia. There is similar enthusiasm for its use in organ preservation for transplant, but also a lack of data. This systematic review aimed to assess the evidence for the efficacy of Custodiol in myocardial protection and as a preservation solution in heart transplant.

METHODS: Electronic searches were performed of six databases from inception to October 2013. Reviewers independently identified studies that compared Custodiol with conventional cardioplegia (blood or extracellular crystalloid) in adult patients for meta-analysis; large case series that reported results using Custodiol were analyzed. Next, we identified studies that compared Custodiol with other organ preservation solutions for organ preservation in heart transplant.

RESULTS: Fourteen studies compared Custodiol with conventional cardioplegia for myocardial protection in adult cardiac surgery. No difference was identified in mortality; there was a trend for increased incidence of ventricular fibrillation in the Custodiol group that did not reach statistical significance. No difference was identified in studies that compared Custodiol with other solutions for heart transplant.

CONCLUSIONS: Despite widespread clinical use, the evidence supporting the superiority of Custodiol over other solutions for myocardial protection or organ preservation is limited. Large randomised trials are required.

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