Surgical aortic valve replacement and patient-prosthesis mismatch: a meta-analysis of 108 182 patients.

OBJECTIVES: This study sought to evaluate the impact of patient-prosthesis mismatch (PPM) on the risk of perioperative, early-, mid- and long-term mortality rates after surgical aortic valve replacement. METHODS: Databases were searched for studies published until March 2018. The main outcomes of interest were perioperative mortality, 1-year mortality, 5-year mortality and 10-year mortality. RESULTS: The search yielded 3761 studies for inclusion. Of these, 70 articles were analysed, and their data were extracted. The total number of patients included was 108 182 who underwent surgical aortic valve replacement. The incidence of PPM after surgical aortic valve replacement was 53.7% (58 116 with PPM and 50 066 without PPM). Perioperative mortality [odds ratio (OR) 1.491, 95% confidence interval (CI) 1.302-1.707; P < 0.001], 1-year mortality (OR 1.465, 95% CI 1.277-1.681; P < 0.001), 5-year mortality (OR 1.358, 95% CI 1.218-1.515; P < 0.001) and 10-year mortality (OR 1.534, 95% CI 1.290-1.825; P < 0.001) were increased in patients with PPM. Both severe PPM and moderate PPM were associated with increased risk of perioperative mortality, 1-year mortality, 5-year mortality and 10-year mortality when analysed together and separately, although we observed a higher risk in the group with severe PPM. CONCLUSIONS: Moderate/severe PPM increases perioperative, early-, mid- and long-term mortality rates proportionally to its severity. The findings of this study support the implementation of surgical strategies to prevent PPM in order to decrease mortality rates.

Baseline and postoperative levels of C-reactive protein and interleukins as inflammatory predictors of atrial fibrillation following cardiac surgery: a systematic review and meta-analysis.

BACKGROUND: Postoperative atrial fibrillation (POAF) is a leading arrhythmia with high incidence and serious clinical implications after cardiac surgery. Cardiac surgery is associated with systemic inflammatory response including increase in cytokines and activation of endothelial and leukocyte responses. AIM: This systematic review and meta-analysis aimed to determine the strength of evidence for evaluating the association of inflammatory markers, such as C-reactive protein (CRP) and interleukins (IL), with POAF following isolated coronary artery bypass grafting (CABG), isolated valvular surgery, or a combination of these procedures. METHODS: We conducted a meta-analysis of studies evaluating measured baseline (from one week before surgical procedures) and postoperative levels (until one week after surgical procedures) of inflammatory markers in patients with POAF. A compre-hensive search was performed in electronic medical databases (Medline/PubMed, Web of Science, Embase, Science Direct, and Google Scholar) from their inception through May 2017 to identify relevant studies. A comprehensive subgroup analysis was performed to explore potential sources of heterogeneity. RESULTS: A literature search of all major databases retrieved 1014 studies. After screening, 42 studies were analysed including a total of 8398 patients. Pooled analysis showed baseline levels of CRP (standard mean difference [SMD] 0.457 mg/L, p < 0.001), baseline levels of IL-6 (SMD 0.398 pg/mL, p < 0.001), postoperative levels of CRP (SMD 0.576 mg/L, p < 0.001), postoperative levels of IL-6 (SMD 1.66 pg/mL, p < 0.001), postoperative levels of IL-8 (SMD 0.839 pg/mL, p < 0.001), and postoperative levels of IL-10 (SMD 0.590 pg/mL, p < 0.001) to be relevant inflammatory parameters significantly associated with POAF. CONCLUSIONS: Perioperative inflammation is proposed to be involved in the pathogenesis of POAF. Therefore, perioperative assessment of CRP, IL-6, IL-8, and IL-10 can help clinicians in terms of predicting and monitoring for POAF.

Haematological indices as predictors of atrial fibrillation following isolated coronary artery bypass grafting, valvular surgery, or combined procedures: a systematic review with meta-analysis.

BACKGROUND: New postoperative atrial fibrillation (POAF) is one of the most critical and common complications after cardiovascular surgery precipitating early and late morbidities. Complete blood count (CBC) is an imperative blood test in clinical practice, routinely used in the examination of cardiovascular diseases. AIM: This systematic review with meta-analysis aimed to determine the strength of evidence for evaluating the association of haematological indices in CBC tests with atrial fibrillation following isolated coronary artery bypass graft (CABG), isolated valvular surgery, or a combination of these treatments. METHODS: We conducted a meta-analysis of studies evaluating pre- and postoperative haematological indices in patients with POAF. A comprehensive subgroup analysis was performed to explore potential sources of heterogeneity. RESULTS: A literature search of all major databases retrieved 732 studies. After screening, 22 studies were analysed including a total of 6098 patients. Pooled analysis showed preoperative platelet count (PC) (weighted mean difference [WMD] = -7.07 × 10^9/L and p < 0.001), preoperative mean platelet volume (MPV) (WMD = 0.53 FL and p < 0.001), preoperative white blood cell count (WBC) (WMD = 0.130 × 10^9/L and p < 0.001), preoperative neutrophil-to-lymphocyte ratio (NLR) (WMD = 0.33 and p < 0.001), preoperative red blood cell distribution width (RDW) (WMD = 0.36% and p < 0.001), postoperative WBC (WMD = 1.36 × 10^9/L and p < 0.001), and postoperative NLR (WMD = 0.74 and p < 0.001) as associated factors with POAF. CONCLUSIONS: Haematological indices may predict the risk of POAF before surgery. These easily-performed tests should definitely be taken into account in patients undergoing isolated CABG, valvular surgery, or combined procedures.

Prediction of New-Onset and Recurrent Atrial Fibrillation by Complete Blood Count Tests: A Comprehensive Systematic Review with Meta-Analysis.

BACKGROUND Atrial fibrillation (AF) is one of the most critical and frequent arrhythmias precipitating morbidities and mortalities. The complete blood count (CBC) test is an important blood test in clinical practice and is routinely used in the workup of cardiovascular diseases. This systematic review with meta-analysis aimed to determine the strength of evidence for evaluating the association of hematological parameters in the CBC test with new-onset and recurrent AF. MATERIAL AND METHODS We conducted a meta-analysis of observational studies evaluating hematologic parameters in patients with new-onset AF and recurrent AF. A comprehensive subgroup analysis was performed to explore potential sources of heterogeneity. RESULTS The literature search of all major databases retrieved 2150 studies. After screening, 70 studies were analyzed in the meta-analysis on new-onset AF and 23 studies on recurrent AF. Pooled analysis on new-onset AF showed platelet count (PC) (weighted mean difference (WMD)=WMD of -26.39×10^9/L and p<0.001), mean platelet volume (MPV) (WMD=0.42 FL and p<0.001), white blood cell (WBC) (WMD=-0.005×10^9/L and p=0.83), neutrophil to lymphocyte ratio (NLR) (WMD=0.89 and p<0.001), and red blood cell distribution width (RDW) (WMD=0.61% and p<0.001) as associated factors. Pooled analysis on recurrent AF revealed PC (WMD=-2.71×109/L and p=0.59), WBC (WMD=0.20×10^9/L (95% CI: 0.08 to 0.32; p=0.002), NLR (WMD=0.37 and p<0.001), and RDW (WMD=0.28% and p<0.001). CONCLUSIONS Hematological parameters have significant ability to predict occurrence and recurrence of AF. Therefore, emphasizing the potential predictive role of hematological parameters for new-onset and recurrent AF, we recommend adding the CBC test to the diagnostic modalities of AF in clinical practice.

Stratification of complexity in congenital heart surgery: comparative study of the Risk Adjustment for Congenital Heart Surgery (RACHS-1) method, Aristotle basic score and Society of Thoracic Surgeons-European Association for Cardio- Thoracic Surgery (STS-EACTS) mortality score.

OBJECTIVE: To determine whether stratification of complexity models in congenital heart surgery (RACHS-1, Aristotle basic score and STS-EACTS mortality score) fit to our center and determine the best method of discriminating hospital mortality. METHODS: Surgical procedures in congenital heart diseases in patients under 18 years of age were allocated to the categories proposed by the stratification of complexity methods currently available. The outcome hospital mortality was calculated for each category from the three models. Statistical analysis was performed to verify whether the categories presented different mortalities. The discriminatory ability of the models was determined by calculating the area under the ROC curve and a comparison between the curves of the three models was performed. RESULTS: 360 patients were allocated according to the three methods. There was a statistically significant difference between the mortality categories: RACHS-1 (1) - 1.3%, (2) - 11.4%, (3)-27.3%, (4) - 50 %, (P<0.001); Aristotle basic score (1) - 1.1%, (2) - 12.2%, (3) - 34%, (4) - 64.7%, (P<0.001); and STS-EACTS mortality score (1) - 5.5 %, (2) - 13.6%, (3) - 18.7%, (4) - 35.8%, (P<0.001). The three models had similar accuracy by calculating the area under the ROC curve: RACHS-1- 0.738; STS-EACTS-0.739; Aristotle- 0.766. CONCLUSION: The three models of stratification of complexity currently available in the literature are useful with different mortalities between the proposed categories with similar discriminatory capacity for hospital mortality.

Stratification of complexity in congenital heart surgery: comparative study of the Risk Adjustment for Congenital Heart Surgery (RACHS-1) method, Aristotle basic score and Society of Thoracic Surgeons-European Association for Cardio- Thoracic Surgery (STS-EACTS) mortality score / Estratificação da complexidade em cirurgias de cardiopatias congênitas: comparação dos modelos Risk Adjustment for Congenital Heart Surgery (RACHS-1), escore básico de Aristóteles e escore de mortalidade da Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STS-EACTS)

Abstract Objective: To determine whether stratification of complexity models in congenital heart surgery (RACHS-1, Aristotle basic score and STS-EACTS mortality score) fit to our center and determine the best method of discriminating hospital mortality. Methods: Surgical procedures in congenital heart diseases in patients under 18 years of age were allocated to the categories proposed by the stratification of complexity methods currently available. The outcome hospital mortality was calculated for each category from the three models. Statistical analysis was performed to verify whether the categories presented different mortalities. The discriminatory ability of the models was determined by calculating the area under the ROC curve and a comparison between the curves of the three models was performed. Results: 360 patients were allocated according to the three methods. There was a statistically significant difference between the mortality categories: RACHS-1 (1) - 1.3%, (2) - 11.4%, (3)-27.3%, (4) - 50 %, (P<0.001); Aristotle basic score (1) - 1.1%, (2) - 12.2%, (3) - 34%, (4) - 64.7%, (P<0.001); and STS-EACTS mortality score (1) - 5.5 %, (2) - 13.6%, (3) - 18.7%, (4) - 35.8%, (P<0.001). The three models had similar accuracy by calculating the area under the ROC curve: RACHS-1- 0.738; STS-EACTS-0.739; Aristotle- 0.766. Conclusion: The three models of stratification of complexity currently available in the literature are useful with different mortalities between the proposed categories with similar discriminatory capacity for hospital mortality. .

Resumo Objetivo: Verificar se os modelos de estratificação da complexidade em cirurgias de cardiopatias congênitas atualmente disponíveis (RACHS-1, escore básico de Aristóteles e escore de mortalidade do STS-EACTS) se adequam ao nosso serviço, determinando o de melhor acurácia em discriminar a mortalidade hospitalar. Métodos: Procedimentos em pacientes menores de 18 anos foram alocados nas categorias propostas pelos modelos de estratificação da complexidade. O desfecho de mortalidade hospitalar foi calculado para cada categoria dos três modelos. Análise estatística foi realizada para verificar se as categorias apresentavam distintas mortalidades dentro de cada modelo. A capacidade discriminatória dos modelos foi determinada pelo cálculo de área sob a curva ROC e uma comparação entre as curvas dos três modelos foi realizada. Resultados: 360 pacientes foram alocados pelos três modelos. Houve diferença estatisticamente significante entre as mortalidades das categorias propostas pelos modelos de RACHS-1 (1) - 1,3%, (2) - 11,4%, (3) - 27,3%, (4) - 50%, (P<0,001); escore básico de Aristóteles (1) - 1,1%, (2) - 12,2%, (3) - 34%, (4) - 64,7%, (P<0,001); e escore de mortalidade do STS-EACTS (1) - 5,5%, (2) - 13,6%, (3) - 18,7%, (4) - 35,8%, (P<0,001). Os três modelos tiveram semelhante capacidade discriminatória para o desfecho de mortalidade hospitalar pelo cálculo da área sob a curva ROC: RACHS-1- 0,738; STS-EACTS- 0,739; Aristóteles- 0,766. Conclusão: Os três modelos de estratificação da complexidade atualmente disponíveis na literatura tiveram utilidade com distintas mortalidades entre as categorias propostas, com semelhante capacidade discriminatória para o desfecho de mortalidade hospitalar. .

Smoking as risk factor for chronic kidney disease: systematic review.

INTRODUCTION: Chronic kidney disease (CKD) and smoking are public health problems. OBJECTIVE: To assess smoking as a risk factor for progression of CKD. METHODS: We conducted a systematic review in Medline, LILACS, SciELO, Google Scholar, Embase and Trials.gov with articles published until February/2013. Were included: cohort, clinical trials and case-control. Performed in humans, aged ≥ 18 years with smoking as a risk factor for progression of CKD. We excluded studies that reported no smoking and CKD in the title or had proposed to reduce smoking. RESULTS: Among 94 citations, 12 articles were selected. Of these, six were multicenter conducted in developed countries, four were randomized. Males predominated 51-76%. There was associated with smoking progression in 11 studies. It was found that the consumption ≥ 15 packs/ year increases the risk of progression of CKD. CONCLUSION: Smoking is a risk factor for progression of CKD.

Tabagismo como fator de risco para a doença renal crônica: revisão sistemática / Smoking as risk factor for chronic kidney disease: systematic review

Introdução: A doença renal crônica (DRC) e o tabagismo são problemas de saúde pública. Objetivo: Analisar o tabagismo como fator risco para a progressão da DRC. Métodos: Realizou-se uma revisão sistemática nas bases Medline, LILACS, SciELO, Google Acadêmico, Trials.gov e Embase com artigos publicados até fevereiro de 2013. Incluíram-se estudos: tipo coorte, ensaios clínicos e caso-controle. Realizados em seres humanos com idade ≥ 18 anos tendo tabagismo como fator de risco para progressão da DRC. Excluíram-se estudos que não referiam tabagismo e DRC no título ou tinham proposta de combate ao fumo. Resultados: Das 94 citações, 12 artigos foram selecionados. Destes, seis eram multicêntricos realizados em países desenvolvidos e quatro foram aleatorizados. Predominou o sexo masculino 51%-76%. Houve progressão associada ao tabagismo em 11 estudos. Identificou-se que o consumo ≥ 15 maços/ ano aumenta o risco de progressão da DRC. Conclusão: Tabagismo é fator de risco para progressão da DRC. .

Introduction: Chronic kidney disease (CKD) and smoking are public health problems. Objective: To assess smoking as a risk factor for progression of CKD. Methods: We conducted a systematic review in Medline, LILACS, SciELO, Google Scholar, Embase and Trials.gov with articles published until February/2013. Were included: cohort, clinical trials and case-control. Performed in humans, aged ≥ 18 years with smoking as a risk factor for progression of CKD. We excluded studies that reported no smoking and CKD in the title or had proposed to reduce smoking. Results: Among 94 citations, 12 articles were selected. Of these, six were multicenter conducted in developed countries, four were randomized. Males predominated 51-76%. There was associated with smoking progression in 11 studies. It was found that the consumption ≥ 15 packs/ year increases the risk of progression of CKD. Conclusion: Smoking is a risk factor for progression of CKD. .

Patency of skeletonized versus pedicled internal thoracic artery in coronary bypass graft surgery: a systematic review, meta-analysis and meta-regression.

BACKGROUND: It is suggested that the skeletonization harvesting technique influences the patency rates of internal thoracic artery (ITA) after coronary artery bypass graft (CABG) surgery in comparison to conventional (pedicled) harvesting. We conducted a meta-analysis to determine whether there is any difference between skeletonized versus pedicled ITA in terms of patency after CABG. METHODS: We performed a systematic-review using MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles to search for studies that performed angiographic evaluation within the first two years after CABG between these two groups until December 2013. The principal summary measures were odds ratio (OR) with 95% Confidence Interval (CI) and P values (statistically significant when <0.05). The OR's were combined across studies using weighted DerSimonian-Laird random effects model and weighted Mantel-Haenszel fixed effects. Meta-analysis, sensitivity analysis and meta-regression were completed using the software Comprehensive Meta-Analysis version 2 (Biostat Inc., Englewood, New Jersey). RESULTS: Five studies involving 1764 evaluated conduits (1145 skeletonized; 619 pedicled) met the eligibility criteria. There was no evidence for important heterogeneity of effects among the studies. The overall OR (95% CI) for graft occlusion showed no statistical significant difference between groups (fixed effect model: OR 1.351, 95% CI 0.408 to 4.471, P = 0.801; random effect model: OR 1.351, 95% CI 0.408 to 4.471, P = 0.801). In sensitivity analysis, no difference regarding to left or right ITA was also observed. In meta-regression, we observed no statistically significant coefficients for graft occlusion and proportion of female, diabetics, renal failure, age, off-pump surgery or urgency, which means that the effect is not modulated by these factors. CONCLUSION: In terms of patency, skeletonized ITA appears to be non-inferior in comparison to pedicled ITA after CABG.

Five-year outcomes following PCI with DES versus CABG for unprotected LM coronary lesions: meta-analysis and meta-regression of 2914 patients.

OBJECTIVE: To compare the safety and efficacy at long-term follow-up of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in patients with unprotected left main coronary artery (ULMCA) disease. METHODS: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for clinical studies that reported outcomes at 5-year follow-up after PCI with DES and CABG for the treatment of ULMCA stenosis. Five studies (1 randomized controlled trial and 4 observational studies) were identified and included a total of 2914 patients (1300 for CABG and 1614 for PCI with DES). RESULTS: At 5-year follow-up, there was no significant difference between the CABG and PCI-DES groups in the risk for death (odds ratio [OR] 1.159, P=0.168 for random effect) or the composite endpoint of death, myocardial infarction, or stroke (OR 1.214, P=0.083). The risk for target vessel revascularization (TVR) was significantly lower in the CABG group compared to the PCI-DES group (OR 0.212, P<0.001). The risk of major adverse cardiac and cerebrovascular events (MACCE) was significantly lower in the CABG group compared to the PCI-DES group (OR 0.526, P<0.001). It was observed no publication bias about outcomes and considerably heterogeneity effect about MACCE. CONCLUSION: CABG surgery remains the best option of treatment for patients with ULMCA disease, with less need of TVR and MACCE rates at long-term follow-up.

Skeletonized versus pedicled internal thoracic artery and risk of sternal wound infection after coronary bypass surgery: meta-analysis and meta-regression of 4817 patients.

It is suggested that the internal thoracic artery (ITA) harvesting technique influences the incidence of sternal wound infection (SWI) after coronary artery bypass graft (CABG). To determine if there is any real difference between skeletonized vs pedicled ITA, we performed a meta-analysis to determine if there is any real difference between these two established techniques in terms of SWI. We performed a systematic review using MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles to search for studies that compared the incidence of SWI after CABG between skeletonized vs pedicled ITA until June 2012. The principal summary measures were odds ratio (OR) with 95% confidence interval (CI) and P values (statistically significant when <0.05). The ORs were combined across studies using the weighted DerSimonian-Laird random effects model and weighted Mantel-Haenszel fixed effects. Meta-analysis, sensitivity analysis and meta-regression were completed using the software Comprehensive Meta-Analysis version 2 (Biostat, Inc., Englewood, NJ, USA). Twenty-two studies involving 4817 patients (2424 skeletonized; 2393 pedicled) met the eligibility criteria. There was no evidence for important heterogeneity of effects among the studies. The overall OR (95% CI) of SWI showed a statistically significant difference in favour of skeletonized ITA (fixed effect model: OR 0.443, 95% CI 0.323-0.608, P < 0.001; random effect model: OR 0.443, 95% CI 0.323-0.608, P < 0.001). In the sensitivity analysis, the difference in favour of skeletonized ITA was also observed in subgroups such as diabetic, bilateral ITA and diabetic with bilateral ITA; we also observed that there was a difference in the type of study, since non-randomized studies together demonstrated the benefit of skeletonized ITA in comparison with pedicled ITA, but the randomized studies together did not show this difference (although close to statistical significance and with the tendency to favour the skeletonized group). In meta-regression, we observed a statistically significant coefficient for SWI and proportion of diabetic patients (coefficient -0.02, 95% CI -0.03 to -0.01, P = 0.016). In conclusion, skeletonized ITA appears to reduce the incidence of postoperative SWI in comparison with pedicled ITA after CABG, with this effect being modulated by the presence of diabetes.

Five-year outcomes following PCI with DES versus CABG for unprotected LM coronary lesions: meta-analysis and meta-regression of 2914 patients / Desfechos de 5 anos do tratamento de lesões de TCE por stents farmacológicos versus CRM: metaanálise e meta-regressão de 2914 pacientes

OBJECTIVE: To compare the safety and efficacy at long-term follow-up of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in patients with unprotected left main coronary artery (ULMCA) disease. METHODS: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for clinical studies that reported outcomes at 5-year follow-up after PCI with DES and CABG for the treatment of ULMCA stenosis. Five studies (1 randomized controlled trial and 4 observational studies) were identified and included a total of 2914 patients (1300 for CABG and 1614 for PCI with DES). RESULTS: At 5-year follow-up, there was no significant difference between the CABG and PCI-DES groups in the risk for death (odds ratio [OR] 1.159, P=0.168 for random effect) or the composite endpoint of death, myocardial infarction, or stroke (OR 1.214, P=0.083). The risk for target vessel revascularization (TVR) was significantly lower in the CABG group compared to the PCI-DES group (OR 0.212, P<0.001). The risk of major adverse cardiac and cerebrovascular events (MACCE) was significantly lower in the CABG group compared to the PCI-DES group (OR 0.526, P<0.001). It was observed no publication bias about outcomes and considerably heterogeneity effect about MACCE. CONCLUSION: CABG surgery remains the best option of treatment for patients with ULMCA disease, with less need of TVR and MACCE rates at long-term follow-up.

OBJETIVO: Comparar segurança e eficácia do seguimento a longo prazo da cirurgia de revascularização miocárdica (CRM) com intervenção coronária percutânea (ICP), utilizando stents farmacológicos (SF) em pacientes com lesão de tronco de coronária esquerda não-protegida (TCE). MÉTODOS: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar e listas de referências artigos relevantes foram escaneados para estudos clínicos que relataram resultados em 5 anos de seguimento após ICP-SF eCRM para o tratamento de lesão de TCE. Cinco estudos (um de ensaio clínico randomizado e quatro estudos observacionais) foram identificados e incluíram um total de 2914 pacientes (1300 para CRM e 1614 para ICP-SF). RESULTADOS: Aos 5 anos de seguimento, não houve diferença significativa entre os grupos CRM e ICP-SF no risco de morte (odds ratio [OR] 1,159, P=0,168) ou desfecho composto de morte, infarto do miocárdio , ou AVC (OR 1,214, P=0,083). O risco de necessidade de nova revascularização foi significativamente menor no grupo CRM em comparação com o grupo de ICP-SF (OR 0,212, P<0,001). O risco de eventos adversos cardíacos maiores e cerebrovasculares (EACMC) foi significativamente menor no grupo CRM em comparação com o grupo de ICP-SF (OR 0,526, P<0,001). Não foi observado viés de publicação sobre os resultados e considerável heterogeneidade dos efeitos sobre EACMC. CONCLUSÃO: CRM continua sendo a melhor opção de tratamento para pacientes com lesão de TCE, com menos necessidade de novas revascularizações e EACMC no seguimento a longo prazo.

Complete versus partial preservation of mitral valve apparatus during mitral valve replacement: meta-analysis and meta-regression of 1535 patients.

OBJECTIVES: To determine if there is any real difference between complete preservation (CP) and partial preservation (PP) of the mitral valve apparatus during mitral valve replacement (MVR) in terms of hard outcomes. METHODS: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for clinical studies that compared outcomes [30-day mortality, postoperative low cardiac output syndrome (LCOS), 5-year mortality or left ventricle ejection fraction (LVEF) before and after surgery] between MVR-CP vs MVR-PP during MVR until July 2012. The principal summary measures were odds ratios (ORs) with 95% confidence interval (CI)--for categorical variables (30-day mortality, postoperative LCOS, 5-year mortality); difference means and standard error (SE)--for continuous variables (LVEF before and after surgery) and P values (that will be considered statistically significant when <0.05). The ORs were combined across studies using DerSimonian-Laird random effects weighted model. The same procedure was executed for continuous variables, taking into consideration the difference in means. RESULTS: Eight studies (2 randomized and 6 non-randomized) were identified and included a total of 1535 patients (597 for MVR-CP and 938 for MVR-PP). There was no significant difference between MVR-CP or MVR-PP groups in the risk for 30-day mortality (OR 0.870; 95% CI 0.50-1.52; P = 0.63) or postoperative LCOS (OR 0.35; 95% CI 0.11-1.08 and P = 0.07) or 5-year mortality (OR 0.70; 95% CI 0.43-1.14; P = 0.15). Taking into consideration LVEF, neither MVR-CP nor MVR-CP demonstrated a statistically significant improvement in LVEF before and after surgery, and both strategies were not different from each other. No publication bias was observed. CONCLUSIONS: We found evidence that argues against any superiority between both techniques of preservation (complete or partial) of mitral valve apparatus during MVR.

Meta-analysis of 5,674 patients treated with percutaneous coronary intervention and drug-eluting stents or coronary artery bypass graft surgery for unprotected left main coronary artery stenosis.

OBJECTIVES: To compare the safety and efficacy of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in patients with unprotected left main coronary artery (ULMCA) disease. METHODS: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for clinical studies that reported outcomes at the 1-year follow-up after PCI with DES and CABG for the treatment of ULMCA stenosis. Sixteen studies (three randomized controlled trials and 13 observational studies) were identified and included a total of 5674 patients (2331 for PCI with DES and 3343 for CABG). RESULTS: At the 1-year follow-up, there was no significant difference between the CABG and DES groups in the risk for death (odds ratio [OR] 0.691, P = 0.051) or the composite endpoint of death, myocardial infarction or stroke (OR 0.832, P = 0.258). The risk for target vessel revascularization (TVR) was significantly higher in the PCI group compared with the CABG group (OR 3.597, P < 0.001). The risk of major adverse cardiac and cerebrovascular events (MACCE) was significantly higher in the PCI group compared with the CABG group (OR 1.607, P < 0.001). A publication bias was observed regarding the outcome of death and also a considerable heterogeneity effect on the composite endpoint of death, myocardial infarction or stroke and MACCE. CONCLUSIONS: CABG surgery remains the best option of treatment for patients with ULMCA disease, with less need of TVR and lower MACCE rates.

Off-pump versus on-pump coronary artery bypass surgery: meta-analysis and meta-regression of 13,524 patients from randomized trials / Cirurgia de revascularização miocárdica com CEC versus sem CEC: meta-análise e meta-regressão de 13.524 pacientes de estudos randomizados

BACKGROUND: Most recent published meta-analysis of randomized controlled trials (RCTs) showed that off-pump coronary artery bypass graft surgery (CABG) reduces incidence of stroke by 30% compared with on-pump CABG, but showed no difference in other outcomes. New RCTs were published, indicating need of new meta-analysis to investigate pooled results adding these further studies. METHODS: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for RCTs that compared outcomes (30-day mortality for all-cause, myocardial infarction or stroke) between off-pump versus on-pump CABG until May 2012. The principal summary measures were relative risk (RR) with 95% Confidence Interval (CI) and P values (considered statistically significant when <0.05). The RR's were combined across studies using DerSimonian-Laird random effects weighted model. Meta-analysis and meta-regression were completed using the software Comprehensive Meta-Analysis version 2 (Biostat Inc., Englewood, New Jersey, USA). RESULTS: Forty-seven RCTs were identified and included 13,524 patients (6,758 for off-pump and 6,766 for on-pump CABG). There was no significant difference between off-pump and on-pump CABG groups in RR for 30-day mortality or myocardial infarction, but there was difference about stroke in favor to off-pump CABG (RR 0.793, 95% CI 0.660-0.920, P=0.049). It was observed no important heterogeneity of effects about any outcome, but it was observed publication bias about outcome "stroke". Meta-regression did not demonstrate influence of female gender, number of grafts or age in outcomes. CONCLUSION: Off-pump CABG reduces the incidence of post-operative stroke by 20.7% and has no substantial effect on mortality or myocardial infarction in comparison to on-pump CABG. Patient gender, number of grafts performed and age do not seem to explain the effect of off-pump CABG on mortality, myocardial infarction or stroke, respectively.

INTRODUÇÃO: A meta-análise mais recente de estudos randomizados controlados (ERC) mostrou que cirurgia de revascularização (CRM) sem circulação extracorpórea (CEC) reduz a incidência de acidente vascular cerebral em 30% em comparação com CRM com CEC, mas não mostrou diferença em outros resultados. Novos ERCs foram publicados, indicando necessidade de nova meta-análise para investigar resultados agrupados adicionando esses estudos. MÉTODOS: MEDLINE, EMBASE, CENTRAL / CCTR, SciELO, LILACS, Google Scholar e listas de referências de artigos relevantes foram pesquisados para ERCs que compararam os resultados de 30 dias (mortalidade por todas as causas, infarto do miocárdio ou acidente vascular cerebral - AVC) entre CRM com CEC versus sem CEC até maio de 2012. As medidas sumárias principais foram o risco relativo (RR) com intervalo de confiança de 95% (IC) e os valores de P (considerado estatisticamente significativo quando <0,05). Os RR foram combinados entre os estudos usando modelo de efeito randômico de DerSimonian-Laird. Meta-análise e meta-regressão foram concluídas usando o software versão Meta-Análise Abrangente 2 (Biostat Inc., Englewood, Nova Jersey, EUA). RESULTADOS: Quarenta e sete ERCs foram identificados e incluíram 13.524 pacientes (6.758 sem CEC e 6.766 com CEC). Não houve diferença significativa entre CRM com CEC e sem CEC no RR de mortalidade em 30 dias ou infarto do miocárdio, mas houve diferença em favor da CRM sem CEC no desfecho AVC (RR 0,793, IC 95% 0,660-0,920, P = 0,049). Não foi observado importante heterogeneidade dos efeitos sobre qualquer resultado, mas observou-se um viés de publicação sobre o desfecho "AVC". Meta-regressão não demonstrou influência do sexo feminino, o número de pontes ou idade nos resultados. CONCLUSÃO: CRM sem uso da CEC reduz a incidência de acidente vascular cerebral pós-operatória de 20,7% e não tem efeito significativo sobre a mortalidade ou infarto do miocárdio em comparação com CRM com CEC. Sexo do paciente, número de enxertos realizados e idade não parecem explicar o efeito de RM sem CEC sobre a mortalidade, infarto do miocárdio ou acidente vascular cerebral, respectivamente.

Preservation versus non-preservation of mitral valve apparatus during mitral valve replacement: a meta-analysis of 3835 patients.

Resection of the chordopapillary apparatus during mitral valve replacement has been associated with a negative impact on survival. Mitral valve replacement with the preservation of the mitral valve apparatus has been associated with better outcomes, but surgeons remain refractory to its use. To determine if there is any real difference in preservation vs non-preservation of mitral valve apparatus during mitral valve replacement in terms of outcomes, we performed a systematic review and meta-analysis using MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles to search for clinical studies that compared outcomes (30-day mortality, postoperative low cardiac output syndrome or 5-year mortality) between preservation vs non-preservation during mitral valve replacement from 1966 to 2011. The principal summary measures were odds ratios (ORs) with 95% confidence interval and P-values (that will be considered statistically significant when <0.05). The ORs were combined across studies using a weighted DerSimonian-Laird random-effects model. The meta-analysis was completed using the software Comprehensive Meta-Analysis version 2 (Biostat Inc., Englewood, NJ, USA). Twenty studies (3 randomized and 17 non-randomized) were identified and included a total of 3835 patients (1918 for mitral valve replacement preservation and 1917 for mitral valve replacement non-preservation). There was significant difference between mitral valve replacement preservation and mitral valve replacement non-preservation groups in the risk of 30-day mortality (OR 0.418, P <0.001), postoperative low cardiac output syndrome (OR 0.299, P <0.001) or 5-year mortality (OR 0.380, P <0.001). No publication bias or important heterogeneity of effects on any outcome was observed. In conclusion, we found evidence that argues in favour of the preservation of mitral valve apparatus during mitral valve replacement.