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A Meta-Analysis of Mitral Valve Repair Versus Replacement for Ischaemic Mitral Regurgitation
Abstracts
Comparison of Cardiac Output of Both 2 and 3 Dimensional Transoesophageal Echocardiography With Transpulmonary Thermodilution During Cardiac Surgery David Canty, A/Prof ∗ , Martin Kim, Dr, Ranj Guha, Dr, Tuan Pham, Dr, Alistair Royse, Prof, Colin Royse, Prof Department of Surgery, University of Melbourne, Melbourne, VIC, Australia Purpose: Transpulmonary thermodilution (TD) is the gold standard for cardiac output (CO) monitoring during cardiac surgery but is feasible with TOE, but 2D TOE underestimates CO due to assumption of a circular LVOT, when 3D TOE demonstrates it is ovoid. The aim of this study is to determine if 3D TOE correlates better with TD than 2-D TOE. Methodology: After ethics approval, 50 adult patients without more than mild valvular regurgitation or A who were scheduled for bypass cardiac surgery were recruited prospectively at two institutions. CO was measured simultaneously by TD and TOE (2D/3D) before and after CPB. CO was calculated using the continuity method (product of VTI, area and heart rate) using the modal and outer-edge trace of the LVOT VTI. The aortic valve area was estimated with planimetry by both 2D and 3D TOE. Agreement analysis was performed using the Deming model II regression analysis and Bland-Altman technique (TD as the reference method). Results: Proportional but not fixed bias was present for the VTI modal method but not for any other method. Correlation for LVOT modal was poor (0.40) and CO was underestimated (mean bias = -1.59 L.min-1), but the limits of agreement were similar to other methods. Tracing the edge of the LVOT VTI rather than the modal line reduced the bias (-0.59 L.min-1), and improved correlation (0.92). 3D planimetry of the AV and continuous wave Doppler had the best agreement with TD. The mean bias approached zero for the 3D methods but with similar limits of agreement. Conclusion: For 2D measurements, tracing around the LVOT VTI rather than through the modal line improved precision. The other 2D and 3D measurements of CO showed absence of bias, and reasonable agreement with TD. http://dx.doi.org/10.1016/j.hlc.2017.03.019 Systematic Review and Meta-Analysis of Uniportal Versus Multiportal VideoAssisted Thoracoscopic Lobectomy for Lung Cancer Christopher Cao, Dr ∗ , Christopher Harris, Rebecca James, David Tian, Mathew Doyle, Diego Gonzalez-Rivas, Tristan Yan The Collaborative Research (CORE) Group, Sydney, NSW, Australia Background: Uniportal video-assisted thoracoscopic surgery (VATS) has emerged as a less invasive alternative to the conventional multiportal approach in the treatment of lung cancer. The benefits of this uniportal technique have not yet been characterised in patients undergoing VATS
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lobectomy. This meta-analysis aimed to compare the clinical outcomes of uniportal and multiportal VATS lobectomy for patients with lung cancer. Methods: A systematic review was conducted using seven electronic databases. Endpoints for analysis included perioperative mortality and morbidity, operative time, length of hospital stay, perioperative blood loss, duration of postoperative drainage and rates of conversion to open thoracotomy. Results: Eight relevant observational studies were identified and included for meta-analysis. Results demonstrated a statistically significant reduction in the overall rate of complications, length of hospital stay and duration of postoperative drainage for patients who underwent uniportal VATS lobectomy. There were no significant differences between the two treatment groups in regard to mortality, operative time, perioperative blood loss and rate of conversion to open thoracotomy. Conclusions: The present meta-analysis demonstrated favourable outcomes for uniportal VATS lobectomy in the treatment of lung cancer compared to the conventional multiportal approach. However, long-term follow-up data is still needed to further characterise the benefits of the uniportal approach. http://dx.doi.org/10.1016/j.hlc.2017.03.020 A Meta-Analysis of Mitral Valve Repair Versus Replacement for Ischaemic Mitral Regurgitation Christopher Cao, Dr ∗ , Sohaib Virk, Arunan Sriravindrarajah, Douglass Dunn, Kevin Liou, Hugh Wolfenden The Collaborative Research (CORE) Group, Sydney, NSW, Australia Background: The development of ischaemic mitral regurgitation (IMR) portends a poor prognosis and is associated with adverse long-term outcomes. Although both mitral valve repair (MVr) and mitral valve replacement (MVR) have been performed in the surgical management of IMR, uncertainty remains regarding the optimal approach. The aim of this study was to meta-analyse these two procedures, with mortality as the primary endpoint. Methods: Seven databases were systematically searched for studies reporting perioperative or late mortality following MVr and MVR for IMR. Data were independently extracted by two reviewers and meta-analysed according to pre-defined study selection criteria and clinical endpoints. Results: Overall, 22 observational studies (n = 3,815 patients) and one randomised controlled trial (n = 251) were included. Meta-analysis demonstrated significantly reduced perioperative mortality [relative risk (RR) 0.61; 95% confidence intervals (CI), 0.47-0.77; I2 = 0%; p < 0.001] and late mortality (RR, 0.78; 95% CI, 0.67-0.92; I2 = 0%; p = 0.002) following MVr. This finding was more pronounced in studies with longer follow-up beyond 3 years. At latest follow-up, recurrence of at least moderate mitral regurgitation (MR) was higher following MVr (RR, 5.21; 95% CI, 2.66-10.22; I2 = 46%; p < 0.001) but the incidence of mitral valve re-operations were similar.
Abstracts
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Conclusions: In the present meta-analysis, MVr was associated with reduced perioperative and late mortality compared to MVR, despite an increased recurrence of at least moderate MR at follow-up. These findings must be considered within the context of the differing patient characteristics that may affect allocation to MVr or MVR. Larger prospective studies are warranted to further compare long-term survival and freedom from re-intervention. http://dx.doi.org/10.1016/j.hlc.2017.03.021 A Systematic Review and Meta-Analysis of Multidetector Computed Tomography Christopher Cao, Dr ∗ , Michael Chan, Douglas Dunn, David Tian, Kevin Liou, Chaitu Cheruvu The Collaborative Research Group, Macquarie University, Sydney, NSW, Australia Background: The present meta-analysis compared the diagnostic accuracy of more recent computed tomography coronary angiography (CTCA) with invasive coronary angiography (ICA) in the assessment of graft patency after coronary artery bypass graft surgery (CABG). Method: A systematic review was performed using nine electronic databases from their dates of inception to July 2015. Predefined inclusion criteria included studies reporting on comparative outcomes using 64 slice multi-detector computed tomography (MDCT) and ICA. The primary endpoints included graft occlusion and significant graft stenosis 50%. Secondary analyses included the comparison of arterial versus venous graft conduits, and the use of different MDCT techniques. Results: Thirty-one studies were identified according to selection criteria, involving 1975 patients with 5364 assessed grafts. Combined assessment of stenosis and occlusion for all grafts demonstrated a sensitivity of 96.1% [95% confidence interval (CI) 94.3-97.4%] and specificity of 96.3% (95% CI 95.1-97.3%). CTCA assessment of venous grafts demonstrated higher sensitivity compared to arterial grafts, when testing for both occlusion and stenosis (97.6% vs. 89.2%, p = 0.004). Conclusion: Results of this study demonstrated that CTCA had a relatively high pooled sensitivity, specificity and negative predictive value compared to ICA. However, patient baseline characteristics varied between studies, and the results should be interpreted with caution. Nonetheless, our results indicate that CTCA should be recognised as an accurate and non-invasive investigation for graft patency in symptomatic patients after CABG. http://dx.doi.org/10.1016/j.hlc.2017.03.022
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Totally Endoscopic Coronary Artery Bypass: A Systematic Review Christopher Cao, Dr ∗ , Praveen Indraratna, Dr, Mathew Doyle, Dr, Sohaib Virk, Dr The Collaborative Research (CORE) Group, Sydney, NSW, Australia Background: Coronary artery bypass graft (CABG) surgery through sternotomy remains the standard treatment for selected patients with coronary artery disease. Recently, totally endoscopic coronary artery bypass (TECAB) procedures have been performed to minimise complications related to sternotomy with the additional goal of faster postoperative recovery. However, there is a paucity of robust clinical data on this novel technique. The aim of the present study was to assess the perioperative and mid-term outcomes of TECAB. Methods: A systematic review was performed using nine electronic databases from their dates of inception to January 2016. Predefined inclusion criteria included studies reporting on perioperative mortality outcomes of patients who underwent TECAB. Results: Twenty-four studies were identified according to selection criteria, including 20 reports on TECAB and four studies comparing TECAB with conventional CABG. The median perioperative mortality rate was 0.3%. Other perioperative outcomes included graft occlusion (1.2%), myocardial infarction (0.5%) stroke (0.5%), conversion to sternotomy (5.2%), and wound infection (1.0%). Median operative time was 228 minutes. Median hospitalisation period was 4 days. There was insufficient comparative data for meta-analysis. Mid-term mortality outcomes for TECAB at the time of latest follow-up was < 1%. Conclusion: The present systematic review presented the most comprehensive data on TECAB to date. Our results indicated that TECAB can be performed safely in specialised centres for selected patients, with acceptable perioperative outcomes. Future prospective studies should focus on comparing TECAB with conventional CABG and refine the patient selection process in the context of hybrid procedures. http://dx.doi.org/10.1016/j.hlc.2017.03.023 A Case of Posterior Mediastinal Cyst of Mullerian Type (Hattori’s Cysts) Nikhil Chandra, Dr ∗ , Siven Seevanayagam, Mr Austin Health, Melbourne, VIC, Australia Cysts in the mediastinum have been previously reported in the literature as being acquired or congenital [1]. The most common of these being Bronchogenic cysts, neuroenteric cysts, oesophageal duplication cysts, pericardial cysts and schwanommas more specific to the posterior mediastinum. We describe a 52-year-old female who presented with a 2month history of intermittent chest pain and shortness of breath and more recently transient numbness down her left arm. Chest X-ray showed a 6 cm posterior mediastinal mass from T4-T7, with normal cardio-mediastinal contours. She
Comparison of Cardiac Output of Both 2 and 3 Dimensional Transoesophageal Echocardiography With Transpulmonary Thermodilution During Cardiac Surgery David Canty, A/Prof ∗ , Martin Kim, Dr, Ranj Guha, Dr, Tuan Pham, Dr, Alistair Royse, Prof, Colin Royse, Prof Department of Surgery, University of Melbourne, Melbourne, VIC, Australia Purpose: Transpulmonary thermodilution (TD) is the gold standard for cardiac output (CO) monitoring during cardiac surgery but is feasible with TOE, but 2D TOE underestimates CO due to assumption of a circular LVOT, when 3D TOE demonstrates it is ovoid. The aim of this study is to determine if 3D TOE correlates better with TD than 2-D TOE. Methodology: After ethics approval, 50 adult patients without more than mild valvular regurgitation or A who were scheduled for bypass cardiac surgery were recruited prospectively at two institutions. CO was measured simultaneously by TD and TOE (2D/3D) before and after CPB. CO was calculated using the continuity method (product of VTI, area and heart rate) using the modal and outer-edge trace of the LVOT VTI. The aortic valve area was estimated with planimetry by both 2D and 3D TOE. Agreement analysis was performed using the Deming model II regression analysis and Bland-Altman technique (TD as the reference method). Results: Proportional but not fixed bias was present for the VTI modal method but not for any other method. Correlation for LVOT modal was poor (0.40) and CO was underestimated (mean bias = -1.59 L.min-1), but the limits of agreement were similar to other methods. Tracing the edge of the LVOT VTI rather than the modal line reduced the bias (-0.59 L.min-1), and improved correlation (0.92). 3D planimetry of the AV and continuous wave Doppler had the best agreement with TD. The mean bias approached zero for the 3D methods but with similar limits of agreement. Conclusion: For 2D measurements, tracing around the LVOT VTI rather than through the modal line improved precision. The other 2D and 3D measurements of CO showed absence of bias, and reasonable agreement with TD. http://dx.doi.org/10.1016/j.hlc.2017.03.019 Systematic Review and Meta-Analysis of Uniportal Versus Multiportal VideoAssisted Thoracoscopic Lobectomy for Lung Cancer Christopher Cao, Dr ∗ , Christopher Harris, Rebecca James, David Tian, Mathew Doyle, Diego Gonzalez-Rivas, Tristan Yan The Collaborative Research (CORE) Group, Sydney, NSW, Australia Background: Uniportal video-assisted thoracoscopic surgery (VATS) has emerged as a less invasive alternative to the conventional multiportal approach in the treatment of lung cancer. The benefits of this uniportal technique have not yet been characterised in patients undergoing VATS
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lobectomy. This meta-analysis aimed to compare the clinical outcomes of uniportal and multiportal VATS lobectomy for patients with lung cancer. Methods: A systematic review was conducted using seven electronic databases. Endpoints for analysis included perioperative mortality and morbidity, operative time, length of hospital stay, perioperative blood loss, duration of postoperative drainage and rates of conversion to open thoracotomy. Results: Eight relevant observational studies were identified and included for meta-analysis. Results demonstrated a statistically significant reduction in the overall rate of complications, length of hospital stay and duration of postoperative drainage for patients who underwent uniportal VATS lobectomy. There were no significant differences between the two treatment groups in regard to mortality, operative time, perioperative blood loss and rate of conversion to open thoracotomy. Conclusions: The present meta-analysis demonstrated favourable outcomes for uniportal VATS lobectomy in the treatment of lung cancer compared to the conventional multiportal approach. However, long-term follow-up data is still needed to further characterise the benefits of the uniportal approach. http://dx.doi.org/10.1016/j.hlc.2017.03.020 A Meta-Analysis of Mitral Valve Repair Versus Replacement for Ischaemic Mitral Regurgitation Christopher Cao, Dr ∗ , Sohaib Virk, Arunan Sriravindrarajah, Douglass Dunn, Kevin Liou, Hugh Wolfenden The Collaborative Research (CORE) Group, Sydney, NSW, Australia Background: The development of ischaemic mitral regurgitation (IMR) portends a poor prognosis and is associated with adverse long-term outcomes. Although both mitral valve repair (MVr) and mitral valve replacement (MVR) have been performed in the surgical management of IMR, uncertainty remains regarding the optimal approach. The aim of this study was to meta-analyse these two procedures, with mortality as the primary endpoint. Methods: Seven databases were systematically searched for studies reporting perioperative or late mortality following MVr and MVR for IMR. Data were independently extracted by two reviewers and meta-analysed according to pre-defined study selection criteria and clinical endpoints. Results: Overall, 22 observational studies (n = 3,815 patients) and one randomised controlled trial (n = 251) were included. Meta-analysis demonstrated significantly reduced perioperative mortality [relative risk (RR) 0.61; 95% confidence intervals (CI), 0.47-0.77; I2 = 0%; p < 0.001] and late mortality (RR, 0.78; 95% CI, 0.67-0.92; I2 = 0%; p = 0.002) following MVr. This finding was more pronounced in studies with longer follow-up beyond 3 years. At latest follow-up, recurrence of at least moderate mitral regurgitation (MR) was higher following MVr (RR, 5.21; 95% CI, 2.66-10.22; I2 = 46%; p < 0.001) but the incidence of mitral valve re-operations were similar.
Abstracts
S360
Conclusions: In the present meta-analysis, MVr was associated with reduced perioperative and late mortality compared to MVR, despite an increased recurrence of at least moderate MR at follow-up. These findings must be considered within the context of the differing patient characteristics that may affect allocation to MVr or MVR. Larger prospective studies are warranted to further compare long-term survival and freedom from re-intervention. http://dx.doi.org/10.1016/j.hlc.2017.03.021 A Systematic Review and Meta-Analysis of Multidetector Computed Tomography Christopher Cao, Dr ∗ , Michael Chan, Douglas Dunn, David Tian, Kevin Liou, Chaitu Cheruvu The Collaborative Research Group, Macquarie University, Sydney, NSW, Australia Background: The present meta-analysis compared the diagnostic accuracy of more recent computed tomography coronary angiography (CTCA) with invasive coronary angiography (ICA) in the assessment of graft patency after coronary artery bypass graft surgery (CABG). Method: A systematic review was performed using nine electronic databases from their dates of inception to July 2015. Predefined inclusion criteria included studies reporting on comparative outcomes using 64 slice multi-detector computed tomography (MDCT) and ICA. The primary endpoints included graft occlusion and significant graft stenosis 50%. Secondary analyses included the comparison of arterial versus venous graft conduits, and the use of different MDCT techniques. Results: Thirty-one studies were identified according to selection criteria, involving 1975 patients with 5364 assessed grafts. Combined assessment of stenosis and occlusion for all grafts demonstrated a sensitivity of 96.1% [95% confidence interval (CI) 94.3-97.4%] and specificity of 96.3% (95% CI 95.1-97.3%). CTCA assessment of venous grafts demonstrated higher sensitivity compared to arterial grafts, when testing for both occlusion and stenosis (97.6% vs. 89.2%, p = 0.004). Conclusion: Results of this study demonstrated that CTCA had a relatively high pooled sensitivity, specificity and negative predictive value compared to ICA. However, patient baseline characteristics varied between studies, and the results should be interpreted with caution. Nonetheless, our results indicate that CTCA should be recognised as an accurate and non-invasive investigation for graft patency in symptomatic patients after CABG. http://dx.doi.org/10.1016/j.hlc.2017.03.022
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Totally Endoscopic Coronary Artery Bypass: A Systematic Review Christopher Cao, Dr ∗ , Praveen Indraratna, Dr, Mathew Doyle, Dr, Sohaib Virk, Dr The Collaborative Research (CORE) Group, Sydney, NSW, Australia Background: Coronary artery bypass graft (CABG) surgery through sternotomy remains the standard treatment for selected patients with coronary artery disease. Recently, totally endoscopic coronary artery bypass (TECAB) procedures have been performed to minimise complications related to sternotomy with the additional goal of faster postoperative recovery. However, there is a paucity of robust clinical data on this novel technique. The aim of the present study was to assess the perioperative and mid-term outcomes of TECAB. Methods: A systematic review was performed using nine electronic databases from their dates of inception to January 2016. Predefined inclusion criteria included studies reporting on perioperative mortality outcomes of patients who underwent TECAB. Results: Twenty-four studies were identified according to selection criteria, including 20 reports on TECAB and four studies comparing TECAB with conventional CABG. The median perioperative mortality rate was 0.3%. Other perioperative outcomes included graft occlusion (1.2%), myocardial infarction (0.5%) stroke (0.5%), conversion to sternotomy (5.2%), and wound infection (1.0%). Median operative time was 228 minutes. Median hospitalisation period was 4 days. There was insufficient comparative data for meta-analysis. Mid-term mortality outcomes for TECAB at the time of latest follow-up was < 1%. Conclusion: The present systematic review presented the most comprehensive data on TECAB to date. Our results indicated that TECAB can be performed safely in specialised centres for selected patients, with acceptable perioperative outcomes. Future prospective studies should focus on comparing TECAB with conventional CABG and refine the patient selection process in the context of hybrid procedures. http://dx.doi.org/10.1016/j.hlc.2017.03.023 A Case of Posterior Mediastinal Cyst of Mullerian Type (Hattori’s Cysts) Nikhil Chandra, Dr ∗ , Siven Seevanayagam, Mr Austin Health, Melbourne, VIC, Australia Cysts in the mediastinum have been previously reported in the literature as being acquired or congenital [1]. The most common of these being Bronchogenic cysts, neuroenteric cysts, oesophageal duplication cysts, pericardial cysts and schwanommas more specific to the posterior mediastinum. We describe a 52-year-old female who presented with a 2month history of intermittent chest pain and shortness of breath and more recently transient numbness down her left arm. Chest X-ray showed a 6 cm posterior mediastinal mass from T4-T7, with normal cardio-mediastinal contours. She