应用杂交技术与冠状动脉旁路移植术治疗中国人群冠状动脉多支病变疗效的Meta分析
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摘要
目的系统评价应用杂交冠状动脉血运重建术(HCR)与传统冠状动脉旁路移植术(CABG)治疗中国人群冠状动脉多支病变的有效性和安全性及其经济价值。方法计算机检索Pub Med、The Cochrane Library(2016年2期)、WanFang Data、CNKI、Web of Science数据库,搜集以国内人群为研究对象并且应用HCR与CABG治疗冠状动脉多支血管病变的病例-对照研究,检索时限均为1996年1月到2016年4月。由2位评价员独立筛选文献、提取资料和评价纳入研究的偏倚风险后,采用RevMan 5.1软件进行Meta分析。结果共纳入9个研究,共计1 231例患者。Meta分析结果显示:HCR组在ICU时间[MD=–25.84,95%CI(–42.55,–9.13),P=0.002]和机械通气时间[MD=–4.06,95%CI(–6.43,–1.69),P=0.000 8]明显短于CABG组,但在术后住院时间[MD=–0.64,95%CI(–2.53,–1.25),P=0.51]、新发房颤发生率[OR=1.41,95%CI(0.86,2.30),P=0.17]以及肾损伤发生率[OR=1.56,95%CI(0.89,2.74),P=0.12],两组差异没有统计学意义;HCR组住院费用[MD=3.42,95%CI(1.27,5.56),P=0.002]高于CABG组。两组在术后死亡率[OR=0.36,95%CI(0.12,1.11),P=0.07]、术后再发心梗率[OR=0.32,95%CI(0.06,1.85),P=0.20]、及再血管化发生率[OR=1.16,95%CI(0.48,2.76),P=0.74]之间差异没有统计学意义。在术后脑血管意外[OR=0.35,95%CI(0.14,0.91),P=0.03]和主要不良心血管事件[OR=0.37,95%CI(0.20,0.70),P=0.002]方面,HCR组的发生率明显低于CABG组患者。结论当前证据表明,HCR比CABG在治疗后的脑血管意外和MACCEs发生率要低,但其在安全性和有效性方面,两组差异无统计学意义。受纳入研究数量和质量的限制,上述结论尚需要开展更多研究予以证实。
Objective To systematically review the efficacy, safety and economic value of hybrid coronary revascularization(HCR) versus coronary artery bypass grafting(CABG) for Chinese patients with multivessel coronary artery disease. Methods We searched Pub Med, Wan Fang Data, CNKI, Web of Science and The Cochrane Library(Issue 2,2016) to collect case-control studies about HCR versus CABG for Chinese patients with coronary multivessel disease from the January 1996 to April 2016. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies, then meta-analysis was performed by using Rev Man 5.1 software. Results A total of 9 studies,involving 1 231 patients were included. The results of meta-analysis showed that: compared with the CABG groups, HCR group had lower length of ICU stay(MD=–25.84, 95% CI –42.55 to –9.13, P=0.002) and intubation time(MD=–4.06, 95% CI–6.43 to –1.69, P=0.000 8). However, there were no significant differences between both groups in the length of hospital stay(MD=–0.64, 95% CI –2.53 to 1.25, P=0.51), the incidence of atrial fibrillation(OR=1.41, 95% CI 0.86 to 2.30, P=0.17) and renal failure(OR=1.56, 95% CI 0.89 to 2.74, P=0.12). No significant differences were found between both groups in mortality(OR=0.36, 95% CI 0.12 to 1.11, P=0.07), the incidence of myocardial infarction(OR=0.32, 95% CI 0.06 to 1.85,P=0.20) and the incidence of target vessel revascularization(OR=1.16, 95% CI 0.48 to 2.76, P=0.74). But the incidence of the stroke(OR=0.35, 95% CI 0.14 to 0.91, P=0.03) and MACCEs(OR=0.37, 95% CI 0.20 to 0.70, P=0.002) of the HCR group were lower than those of the patients of the CABG group. Conclusion The current evidence shows that, compared with the CABG groups, HCR had lower incidence of stroke and MACCEs, however, the safety and efficacy were not significantly different between both groups. Due to the limited quantity and quality of the included studies, more high quality studies are needed to verify the above conclusion.
Objective To systematically review the efficacy, safety and economic value of hybrid coronary revascularization(HCR) versus coronary artery bypass grafting(CABG) for Chinese patients with multivessel coronary artery disease. Methods We searched Pub Med, Wan Fang Data, CNKI, Web of Science and The Cochrane Library(Issue 2,2016) to collect case-control studies about HCR versus CABG for Chinese patients with coronary multivessel disease from the January 1996 to April 2016. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies, then meta-analysis was performed by using Rev Man 5.1 software. Results A total of 9 studies,involving 1 231 patients were included. The results of meta-analysis showed that: compared with the CABG groups, HCR group had lower length of ICU stay(MD=–25.84, 95% CI –42.55 to –9.13, P=0.002) and intubation time(MD=–4.06, 95% CI–6.43 to –1.69, P=0.000 8). However, there were no significant differences between both groups in the length of hospital stay(MD=–0.64, 95% CI –2.53 to 1.25, P=0.51), the incidence of atrial fibrillation(OR=1.41, 95% CI 0.86 to 2.30, P=0.17) and renal failure(OR=1.56, 95% CI 0.89 to 2.74, P=0.12). No significant differences were found between both groups in mortality(OR=0.36, 95% CI 0.12 to 1.11, P=0.07), the incidence of myocardial infarction(OR=0.32, 95% CI 0.06 to 1.85,P=0.20) and the incidence of target vessel revascularization(OR=1.16, 95% CI 0.48 to 2.76, P=0.74). But the incidence of the stroke(OR=0.35, 95% CI 0.14 to 0.91, P=0.03) and MACCEs(OR=0.37, 95% CI 0.20 to 0.70, P=0.002) of the HCR group were lower than those of the patients of the CABG group. Conclusion The current evidence shows that, compared with the CABG groups, HCR had lower incidence of stroke and MACCEs, however, the safety and efficacy were not significantly different between both groups. Due to the limited quantity and quality of the included studies, more high quality studies are needed to verify the above conclusion.
引文
1李俊红,木拉提,阿布都乃比.冠状动脉旁路移植术治疗冠脉多支病变长期疗效的Meta分析.中国循证医学杂志,2016,16(4):403-408.
2Angelini GD,Wilde P,Salerno T A,et al.Itegrated left small thoracotomy and angioplasty for multivessel coronary artery revascularisaton.Lancet,1996,347(9003):757-758.
3Hillis LD,Smith PK,Anderson JL,et al.2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery.A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.Developed in collaboration with the American Association for Thoracic Surgery,Society of Cardiovascular Anesthesiologists,and Society of Thoracic Surgeons.J Am Coll Cardiol,2011,58(24):e123-e210.
4邬禕程.杂交技术与冠状动脉旁路移植术治疗冠状动脉多支血管病变的对比研究.上海:上海交通大学,2012.
5袁杰林.杂交冠脉血运重建与冠脉旁路移植术治疗冠状动脉多支病变的荟萃分析.南宁:广西医科大学,2015.
6Hu F,Cui L.Short-term clinical outcomes after hybrid coronary revascularization versus off-pump coronary artery bypass for the treatment of multivessel or left main coronary artery disease:a meta-analysis.Coron Artery Dis,2015,26(6):526-534.
7Zhu P,Zhou P,Sun Y.Hybrid coronary revascularization versus coronary artery bypass grafting for multivessel coronary artery disease:systematic review and meta-analysis.J Cardiothorac Surg,2015,(10):63.
8赵强,夏利民,陈安清,等.杂交技术在冠状动脉外科中的应用.中国微创外科杂志,2006,6(6):421-422.
9Stang A.Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in metaanalyses.Eur J Epidemiol,2010,25(9):603-605.
10Wells GA,Shea B,O'Connell D,et al.The Newcastle-Ottawa Scale(NOS)for assessing the quality of nonrandomized studies in metaanalyses.Available at:http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp
11Wells GA,Shea B,O'Connell D,et al.New Castle-Ottawa Quality Assessment Scale.Available at:http://www.ohri.ca/programs/clinical_epidemiology/nosgen.pdf.
12曾宪涛,刘慧,陈曦,等.Meta分析系列之四:观察性研究的质量评价工具.中国循证心血管医学杂志,2012,4(4):297-299.
13陈泽鑫,刘慧,潘益峰,等.试验性和观察性研究相关医学文献质量评价方法.中国循证医学杂志,2011,11(11):1229-1236.
14王丹,翟俊霞,牟振云,等.Meta分析中的异质性及其处理方法.中国循证医学杂志,2009,9(10):1115-1118.
15王浩然.一站式复合冠状动脉血运重建术与冠状动脉旁路移植术及经皮冠状动脉介入治疗冠状动脉多支病变中期疗效的对比研究.北京:北京协和医学院,2012.
16田真,孙雪峰,刘冬娜,等.298例冠状动脉性心脏病的临床分析.中国实验诊断学,2015,19(9):1529-1530.
17滕志华,董爱强,孔敏坚,等.一站式杂交技术与传统手术治疗复杂冠心病的临床研究.浙江医学,2015,37(10):816-819.
18刘帅.机器人分站式杂交技术治疗冠心病多支病变的中期效果分析–与传统非体外循环冠状动脉旁路移植术对比.北京:中国人民解放军医学院,2014.
19高卿,凌云鹏,卢明喻,等.择期分站式杂交手术与非体外循环冠状动脉旁路移植治疗冠状动脉多支血管病变的对比研究.中国微创外科杂志,2015,15(11):961-964.
20Hu S,Li Q,Gao P,et al.Simultaneous Hybrid Revascularization Versus Off-Pump Coronary Artery Bypass for Multivessel Coronary Artery Disease.Ann Thorac Surg,2011,91(2):432-439.
21潘砚鹏,袁义强,陈红卫,等.分站式杂交技术与非体外循环冠状动脉移植术治疗冠状动脉多支病变的对比研究.心肺血管病杂志,2015,34(12):890-893.
22凌云鹏,卢明喻,鲍黎明,等.分站式杂交手术治疗冠状动脉多支血管病变.中国循环杂志,2014,29(2):90-93.
23Zhou S,Fang Z,Xiong H,et al.Effect of one-stop hybrid coronary revascularization on postoperative renal function and bleeding:a comparison study with off-pump coronary artery bypass grafting surgery.J Thorac Cardiovasc Surg,2014,147(5):1511-1516.
24Shen L,Hu S,Wang H,et al.One-stop hybrid coronary revascularization versus coronary artery bypass grafting and percutaneous coronary intervention for the treatment of multivessel coronary artery disease:3-Year follow-up results from a single institution.J Am Coll Cardiol,2013,61(25):2525-2533.
25陈思,董念国.心血管外科杂交技术的应用与发展现状.中国胸心血管外科临床杂志,2008,15(6):458-461.
26Harskamp RE,Zheng Z,Alexander JH,et al.Status quo of hybrid coronary revascularization for multi-vessel coronary artery disease.Ann Thorac Surg,2013,96(6):2268-2277.
27Harskamp RE,Bagai A,Halkos ME,et al.Clinical outcomes after hybrid coronary revascularization versus coronary artery bypass surgery:a meta-analysis of 1,190 patients.Am Heart J,2014,167(4):585-592.
28赵强.前程似锦,任重道远–冠状动脉杂交血运重建的现在与未来.国际心血管病杂志,2016,43(1):1-3.
2Angelini GD,Wilde P,Salerno T A,et al.Itegrated left small thoracotomy and angioplasty for multivessel coronary artery revascularisaton.Lancet,1996,347(9003):757-758.
3Hillis LD,Smith PK,Anderson JL,et al.2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery.A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.Developed in collaboration with the American Association for Thoracic Surgery,Society of Cardiovascular Anesthesiologists,and Society of Thoracic Surgeons.J Am Coll Cardiol,2011,58(24):e123-e210.
4邬禕程.杂交技术与冠状动脉旁路移植术治疗冠状动脉多支血管病变的对比研究.上海:上海交通大学,2012.
5袁杰林.杂交冠脉血运重建与冠脉旁路移植术治疗冠状动脉多支病变的荟萃分析.南宁:广西医科大学,2015.
6Hu F,Cui L.Short-term clinical outcomes after hybrid coronary revascularization versus off-pump coronary artery bypass for the treatment of multivessel or left main coronary artery disease:a meta-analysis.Coron Artery Dis,2015,26(6):526-534.
7Zhu P,Zhou P,Sun Y.Hybrid coronary revascularization versus coronary artery bypass grafting for multivessel coronary artery disease:systematic review and meta-analysis.J Cardiothorac Surg,2015,(10):63.
8赵强,夏利民,陈安清,等.杂交技术在冠状动脉外科中的应用.中国微创外科杂志,2006,6(6):421-422.
9Stang A.Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in metaanalyses.Eur J Epidemiol,2010,25(9):603-605.
10Wells GA,Shea B,O'Connell D,et al.The Newcastle-Ottawa Scale(NOS)for assessing the quality of nonrandomized studies in metaanalyses.Available at:http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp
11Wells GA,Shea B,O'Connell D,et al.New Castle-Ottawa Quality Assessment Scale.Available at:http://www.ohri.ca/programs/clinical_epidemiology/nosgen.pdf.
12曾宪涛,刘慧,陈曦,等.Meta分析系列之四:观察性研究的质量评价工具.中国循证心血管医学杂志,2012,4(4):297-299.
13陈泽鑫,刘慧,潘益峰,等.试验性和观察性研究相关医学文献质量评价方法.中国循证医学杂志,2011,11(11):1229-1236.
14王丹,翟俊霞,牟振云,等.Meta分析中的异质性及其处理方法.中国循证医学杂志,2009,9(10):1115-1118.
15王浩然.一站式复合冠状动脉血运重建术与冠状动脉旁路移植术及经皮冠状动脉介入治疗冠状动脉多支病变中期疗效的对比研究.北京:北京协和医学院,2012.
16田真,孙雪峰,刘冬娜,等.298例冠状动脉性心脏病的临床分析.中国实验诊断学,2015,19(9):1529-1530.
17滕志华,董爱强,孔敏坚,等.一站式杂交技术与传统手术治疗复杂冠心病的临床研究.浙江医学,2015,37(10):816-819.
18刘帅.机器人分站式杂交技术治疗冠心病多支病变的中期效果分析–与传统非体外循环冠状动脉旁路移植术对比.北京:中国人民解放军医学院,2014.
19高卿,凌云鹏,卢明喻,等.择期分站式杂交手术与非体外循环冠状动脉旁路移植治疗冠状动脉多支血管病变的对比研究.中国微创外科杂志,2015,15(11):961-964.
20Hu S,Li Q,Gao P,et al.Simultaneous Hybrid Revascularization Versus Off-Pump Coronary Artery Bypass for Multivessel Coronary Artery Disease.Ann Thorac Surg,2011,91(2):432-439.
21潘砚鹏,袁义强,陈红卫,等.分站式杂交技术与非体外循环冠状动脉移植术治疗冠状动脉多支病变的对比研究.心肺血管病杂志,2015,34(12):890-893.
22凌云鹏,卢明喻,鲍黎明,等.分站式杂交手术治疗冠状动脉多支血管病变.中国循环杂志,2014,29(2):90-93.
23Zhou S,Fang Z,Xiong H,et al.Effect of one-stop hybrid coronary revascularization on postoperative renal function and bleeding:a comparison study with off-pump coronary artery bypass grafting surgery.J Thorac Cardiovasc Surg,2014,147(5):1511-1516.
24Shen L,Hu S,Wang H,et al.One-stop hybrid coronary revascularization versus coronary artery bypass grafting and percutaneous coronary intervention for the treatment of multivessel coronary artery disease:3-Year follow-up results from a single institution.J Am Coll Cardiol,2013,61(25):2525-2533.
25陈思,董念国.心血管外科杂交技术的应用与发展现状.中国胸心血管外科临床杂志,2008,15(6):458-461.
26Harskamp RE,Zheng Z,Alexander JH,et al.Status quo of hybrid coronary revascularization for multi-vessel coronary artery disease.Ann Thorac Surg,2013,96(6):2268-2277.
27Harskamp RE,Bagai A,Halkos ME,et al.Clinical outcomes after hybrid coronary revascularization versus coronary artery bypass surgery:a meta-analysis of 1,190 patients.Am Heart J,2014,167(4):585-592.
28赵强.前程似锦,任重道远–冠状动脉杂交血运重建的现在与未来.国际心血管病杂志,2016,43(1):1-3.