Mechanical versus bioprosthetic valves in chronic dialysis: a systematic review and meta-analysis.

BACKGROUND: Many patients with end-stage kidney disease (ESKD) have valvular heart disease requiring surgery. The optimal prosthetic valve is not established in this population. We performed a systematic review and meta-analysis to assess outcomes of patients with dialysis-dependent ESKD who received mechanical or bioprosthetic valves. METHODS: We searched Cochrane Central, Medline and Embase from inception to January 2020. We performed screening, full-text assessment, risk of bias and data collection, independently and in duplicate. Data were pooled using a random-effects model. RESULTS: We identified 28 observational studies (n = 9857 patients, including 6680 with mechanical valves and 3717 with bioprosthetic valves) with a median follow-up of 3.45 years. Twenty-two studies were at high risk of bias and 1 was at critical risk of bias from confounding. Certainty in evidence was very low for all outcomes except bleeding. Mechanical valves were associated with reduced mortality at 30 days (relative risk [RR] 0.79, 95% confidence interval [CI] 0.65-0.97, I 2 = 0, absolute effect 27 fewer deaths per 1000) and at 6 or more years (mean 9.7 yr, RR 0.83, 95% CI 0.72-0.96, I 2 = 79%, absolute effect 145 fewer deaths per 1000), but increased bleeding (incidence rate ratio [IRR] 2.46, 95% CI 1.41-4.27, I 2 = 59%, absolute effect 91 more events per 1000) and stroke (IRR 1.63, 95% CI 1.21-2.20, I 2 = 0%, absolute effect 25 more events per 1000). CONCLUSION: Mechanical valves were associated with reduced mortality, but increased rate of bleeding and stroke. Given very low certainty for evidence of mortality and stroke outcomes, patients and clinicians may choose prosthetic valves based on factors such as bleeding risk and valve longevity. STUDY REGISTRATION: PROSPERO no. CRD42017081863.

Outcomes of sutureless aortic valve replacement versus conventional aortic valve replacement and transcatheter aortic valve replacement, updated systematic review, and meta-analysis.

BACKGROUND: Sutureless aortic valve replacement (SuAVR) is an alternative to surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). This study compares the effectiveness of SuAVR to SAVR and TAVR. METHODS: We searched MEDLINE and EMBASE from inception to July 2021 for studies evaluating SuAVR, SAVR, and TAVR in adults with aortic stenosis. We performed screening, full-text assessment, data collection, and risk of bias evaluation independently and in duplicate. We evaluated risk of bias using by Cochrane and CLARITY's tools, and certainty in evidence using the GRADE framework. Data were pooled using a random-effects model. RESULTS: We identified one randomized and 78 observational studies (n = 60,689; SuAVR vs. SAVR = 39,171, vs. TAVR = 21,518). All studies were at high or unclear risk of bias, with very-low certainty in effect estimates. Compared to TAVR, SuAVR demonstrates no significant difference in mortality at 30-days (odds ratio [OR]: 0.52, 95% confidence interval [CI: 0.85, 1.16], I2 = 0%), but decreased odds at 2-years (OR: 0.39, 95% CI [0.17, 0.88], I2 = 0%). SuAVR also reduced odds of mild paravalvular regurgitation (OR: 0.11, 95% CI [0.06, 0.21], I2 = 50%). Compared to SAVR, SuAVR was associated with a similar mortality at 30-days (OR: 0.99, 95% CI [0.85, 1.16], I2 = 0%) and 2-years (OR: 0.99, 95% CI [0.43-2.30], I2 = 7%). SuAVR significantly increased odds of permanent pacemaker implantation (OR: 2.5, 95% CI [2.25, 2.77], I2 = 0%). Pooled effect estimates were consistent with results from the randomized trial comparing SuAVR and SAVR. CONCLUSION: Based on very-low quality evidence, SuAVR is associated with similar short- and midterm outcomes compared to TAVR and SAVR. Comparative randomized data with long-term follow-up are required to clarify the role of SuAVR.

A Randomized Comparison of 2 Robotic Virtual Reality Simulators and Evaluation of Trainees' Skills Transfer to a Simulated Robotic Urethrovesical Anastomosis Task.

OBJECTIVE: To determine, via a randomized comparison study, whether robotic simulator-acquired skills transfer to performance of a urethrovesical anastomosis (UVA) on a 3-dimensional-printed bladder model using the da Vinci Robot. MATERIALS AND METHODS: Medical students, surgical residents, and fellows were recruited and divided into 2 groups: Group 1 (G1) (junior trainees) and Group 2 (G2) (senior trainees). Participants were randomized to identical simulator training curricula on the dV-Trainer (dV-T) or da Vinci Surgical Skills Simulator (dVSSS). Participants then completed a UVA task on a 3-dimensional-printed bladder model using the da Vinci robot. Three blinded expert robotic surgeons rated videotaped performances of the UVA task using validated assessment tools, namely, the Global Evaluative Assessment of Robotic Skills (GEARS; overall procedure) and Robotic Anastomosis Competence Evaluation (RACE; specific to UVA). RESULTS: Thirty-nine participants (G1 = 23 and G2 = 16) completed the study. Participants in G2 had significantly more simulation and surgical experience compared with G1 (P <.05). UVA scores of the dVSSS group were higher compared with dV-T (GEARS: P = .09; RACE: P = .01). In the G1 cohort, dVSSS scores were significantly higher than dV-T (GEARS: P = .01; RACE: P <.01). In the G2 cohort, scores were statistically similar (GEARS: P = .32; RACE: P = .91). CONCLUSION: Compared with the dV-T, the dVSSS training led to superior GEARS and RACE scores for performance of the UVA task in junior trainees, but not in senior trainees. The dVSSS can be used to improve surgical skills acquisition in less experienced trainees in a safe and effective manner.