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The European Journal of Health... Mar 2018To review the evidence on the cost-effectiveness of heart valve implantations generated by decision analytic models and to assess their methodological quality. (Review)
Review
OBJECTIVE
To review the evidence on the cost-effectiveness of heart valve implantations generated by decision analytic models and to assess their methodological quality.
METHODS
A systematic review was performed including model-based cost-effectiveness analyses of heart valve implantations. Study and model characteristics and cost-effectiveness results were extracted and the methodological quality was assessed using the Philips checklist.
RESULTS
Fourteen decision-analytic models regarding the cost-effectiveness of heart valve implantations were identified. In most studies transcatheter aortic valve implantation (TAVI) was cost-effective compared to standard treatment (ST) in inoperable or high-risk operable patients (ICER range 18,421-120,779 €) and in all studies surgical aortic valve replacement (SAVR) was cost-effective compared to ST in operable patients (ICER range 14,108-40,944 €), but the results were not consistent on the cost-effectiveness of TAVI versus SAVR in high-risk operable patients (ICER range: dominant to dominated by SAVR). Mechanical mitral valve replacement (MVR) had the lowest costs per success compared to mitral valve repair and biological MVR. The methodological quality of the studies was moderate to good.
CONCLUSION
This review showed that improvements can be made in the description and justification of methods and data sources, sensitivity analysis on extrapolation of results, subgroup analyses, consideration of methodological and structural uncertainty, and consistency (i.e. validity) of the models. There are several opportunities for future decision-analytic models of the cost-effectiveness of heart valve implantations: considering heart valve implantations in other valve positions besides the aortic valve, using a societal perspective, and developing patient-simulation models to investigate the impact of patient characteristics on outcomes.
Topics: Aortic Valve Stenosis; Cost-Benefit Analysis; Heart Valve Prosthesis Implantation; Heart Valves; Humans; Models, Economic; Risk Assessment
PubMed: 28265822
DOI: 10.1007/s10198-017-0880-z -
Future Cardiology Apr 2022To determine the prognosis of multivalvular disease in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. Patients... (Review)
Review
To determine the prognosis of multivalvular disease in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. Patients undergoing TAVR for aortic stenosis with covariate-adjusted risk of mortality associated with concomitant valve disease (mitral regurgitation [MR], mitral stenosis [MS] or tricuspid regurgitation [TR]) were included. Moderate-to-severe MR was associated with increased mortality at 30 days (hazard ratio [HR]: 1.60; 95% CI: 1.11-2.30; p = 0.01) and 1 year (HR: 1.87; 95% CI: 1.22-2.87; p = 0.004). The presence of all-grade MS did not impact 30-day or 1-year mortality (HR, 30 days: 1.60; 95% CI: 0.71-3.63; p = 0.26; and HR, 1 year: 1.90; 95% CI: 0.98-3.69; p = 0.06); however, an increased risk of 1-year mortality (HR: 1.67; 95% CI: 1.03-2.70; p = 0.04) was observed with severe MS compared with no MS. Moderate-to-severe TR had a higher risk of all-cause mortality at 1 year (HR: 1.49; 95% CI: 1.24-1.78; p < 0.001) compared with no or mild TR. Moderate-to-severe MR or TR, and severe MS, significantly increase mid-term mortality after TAVR.
PubMed: 35485390
DOI: 10.2217/fca-2021-0061 -
Annals of Thoracic and Cardiovascular... Jun 2022Concomitant mitral regurgitation (MR) is frequently seen in patients undergoing surgical aortic valve replacement (AVR) for severe aortic stenosis (AS). When the...
BACKGROUND
Concomitant mitral regurgitation (MR) is frequently seen in patients undergoing surgical aortic valve replacement (AVR) for severe aortic stenosis (AS). When the severity of MR is moderate or less, the decision to undertake simultaneous mitral valve intervention can be challenging.
METHODS
A systematic search of Medline, PubMed (NCBI), Embase and Cochrane Library was conducted to qualitatively assess the current evidence for concomitant mitral valve intervention for MR in patients with AS undergoing AVR. The primary outcome for this systematic review was the postoperative change in the severity of MR and other outcomes of interest included factors that predict improvement or persistence of MR and long-term impacts of residual MR.
RESULTS
A total of 17 studies were included. The percentage of patients demonstrating improvement in MR severity following AVR ranged from 17.2% to 72%; the studies that exclusively included patients with moderate functional MR and reported longer term echocardiographic follow-up of greater than 12 months demonstrated an improvement in MR severity of 45% to 72%.
CONCLUSION
This systematic review demonstrates that a proportion of patients can exhibit an improvement in MR following isolated surgical AVR, but whether this confers any long-term morbidity and mortality benefit remains unclear.
Topics: Aortic Valve; Aortic Valve Stenosis; Heart Valve Prosthesis Implantation; Humans; Mitral Valve Insufficiency; Retrospective Studies; Severity of Illness Index; Treatment Outcome
PubMed: 35135933
DOI: 10.5761/atcs.oa.21-00170 -
Cardiology in Review 2018Rheumatic heart disease (RHD) is an important cause of heart disease globally. Its management can encompass medical and procedural (catheter and surgical) interventions.... (Review)
Review
Rheumatic heart disease (RHD) is an important cause of heart disease globally. Its management can encompass medical and procedural (catheter and surgical) interventions. Literature pertaining to the medical management of RHD from PubMed 1990-2016 and via selected article reference lists was reviewed. Areas included symptom management, left ventricular dysfunction, rate control in mitral stenosis, atrial fibrillation, anticoagulation, infective endocarditis prophylaxis, and management in pregnancy. Diuretics, angiotensin blockade and beta-blockers for left ventricular dysfunction, and beta-blockers and If inhibitors for rate control in mitral stenosis reduced symptoms and improved left ventricular function, but did not alter disease progression. Rhythm control for atrial fibrillation was preferred, and where this was not possible, rate control with beta-blockers was recommended. Anticoagulation was indicated where there was a history of cardioembolism, atrial fibrillation, spontaneous left atrial contrast, and mechanical prosthetic valves. While warfarin remained the agent of choice for mechanical valve implantation, non-vitamin K antagonist oral anticoagulants may have a role in RHD-related AF, particularly with valvular regurgitation. Evidence for anticoagulation after bioprosthetic valve implantation or mitral valve repair was limited. RHD patients are at increased risk of endocarditis, but the evidence supporting antibiotic prophylaxis before procedures that may induce bacteremia is limited and recommendations vary. The management of RHD in pregnancy presents particular challenges, especially regarding decompensation of previously stable disease, the choice of anticoagulation, and the safety of medications in both pregnancy and breast feeding.
Topics: Atrial Fibrillation; Disease Management; Endocarditis; Female; Humans; Male; Mitral Valve Stenosis; Pregnancy; Rheumatic Heart Disease
PubMed: 29608495
DOI: 10.1097/CRD.0000000000000185 -
Herz Apr 2021Since readmission rate is an important clinical index to determine the quality of inpatient care and hospital performance, the aim of this study was to explain the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Since readmission rate is an important clinical index to determine the quality of inpatient care and hospital performance, the aim of this study was to explain the causes and predictors of readmission following transcatheter aortic valve implantation (TAVI) at short-term and mid-term follow-up.
METHODS AND RESULTS
A systematic review and meta-analysis of all published articles from Embase, Pubmed/MEDLINE, and Ovid was carried out. In all, 10 studies including 52,702 patients were identified. The pooled estimate for the overall event rate was 0.15, and cardiovascular causes were the main reason for 30-day readmission (0.42, 95% confidence interval [CI]: 0.39-0.45). In addition, the pooled incidence of 1‑year readmission was 0.31, and cardiovascular events were still the main cause (0.41, 95% CI: 0.33-0.48). Patients with major and life-threatening bleeding, new permanent pacemaker implantation, and clinical heart failure were associated with a high risk for early readmission after TAVI. Moreover, an advanced (≥3) New York Heart Association classification, acute kidney injury, paravalvular leak, mitral regurgitation (≥ moderate), and major bleeding predicted unfavorable outcome to 1‑year readmission. Female gender and transfemoral TAVI was associated with a lower risk for unplanned rehospitalization.
CONCLUSIONS
This meta-analysis found cardiovascular factors to be the main causes for both 30-day and 1‑year rehospitalization. Heart failure represented the most common cardiovascular event at both short-term and mid-term follow-up. Several baseline characteristics and procedure-related factors were deemed unfavorable predictors of readmission. Importantly, transfemoral access and female gender were associated with a lower risk of readmission.
Topics: Aortic Valve; Aortic Valve Stenosis; Female; Heart Valve Prosthesis; Humans; Mitral Valve Insufficiency; Patient Readmission; Postoperative Complications; Risk Factors; Transcatheter Aortic Valve Replacement; Treatment Outcome
PubMed: 31807789
DOI: 10.1007/s00059-019-04870-6 -
PloS One 2021Associations between rheumatic heart disease (RHD) in pregnancy and fetal outcomes are relatively unknown. This study aimed to review rates and predictors of major... (Meta-Analysis)
Meta-Analysis
PURPOSE
Associations between rheumatic heart disease (RHD) in pregnancy and fetal outcomes are relatively unknown. This study aimed to review rates and predictors of major adverse fetal outcomes of RHD in pregnancy.
METHODS
Medline (Ovid), Pubmed, EMcare, Scopus, CINAHL, Informit, and WHOICTRP databases were searched for studies that reported rates of adverse perinatal events in women with RHD during pregnancy. Outcomes included preterm birth, intra-uterine growth restriction (IUGR), low-birth weight (LBW), perinatal death and percutaneous balloon mitral valvuloplasty intervention. Meta-analysis of fetal events by the New-York Heart Association (NYHA) heart failure classification, and the Mitral-valve Area (MVA) severity score was performed with unadjusted random effects models and heterogeneity of risk ratios (RR) was assessed with the I2 statistic. Quality of evidence was evaluated using the GRADE approach. The study was registered in PROSPERO (CRD42020161529).
FINDINGS
The search identified 5949 non-duplicate records of which 136 full-text articles were assessed for eligibility and 22 studies included, 11 studies were eligible for meta-analyses. In 3928 pregnancies, high rates of preterm birth (9.35%-42.97%), LBW (12.98%-39.70%), IUGR (6.76%-22.40%) and perinatal death (0.00%-9.41%) were reported. NYHA III/IV pre-pregnancy was associated with higher rates of preterm birth (5 studies, RR 2.86, 95%CI 1.54-5.33), and perinatal death (6 studies, RR 3.23, 1.92-5.44). Moderate /severe mitral stenosis (MS) was associated with higher rates of preterm birth (3 studies, RR 2.05, 95%CI 1.02-4.11) and IUGR (3 studies, RR 2.46, 95%CI 1.02-5.95).
INTERPRETATION
RHD during pregnancy is associated with adverse fetal outcomes. Maternal NYHA III/IV and moderate/severe MS in particular may predict poor prognosis.
Topics: Female; Humans; Infant; Infant Mortality; Infant, Newborn; Mitral Valve Stenosis; Pregnancy; Pregnancy Complications, Cardiovascular; Premature Birth; Rheumatic Heart Disease
PubMed: 34185797
DOI: 10.1371/journal.pone.0253581 -
Catheterization and Cardiovascular... Jan 2018To summarize the published data of combined transcatheter aortic and mitral valve intervention (CTAMVI).
OBJECTIVES
To summarize the published data of combined transcatheter aortic and mitral valve intervention (CTAMVI).
BACKGROUND
CTAMVI, a combination of either transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve-in-valve (TAViV) and transcatheter mitral valve replacement (TMVR), transcatheter mitral valve-in-valve/valve-in-ring (TMViV/ViR), or percutaneous mitral valve repair (PMVR) is an attractive alternative in high-surgical risk patients with combined aortic and mitral valve disease. However, its procedural details and clinical outcomes have not been well described.
METHODS
We performed a systematic review of all the published articles from PUBMED and EMBASE.
RESULTS
A total of 37 studies with 60 patients were included. The indication for CTAMVI was high or inoperable surgical risk and symptomatic severe aortic stenosis (92%) or severe aortic regurgitation (8%) combined with moderate to severe/severe mitral stenosis (30%) or moderate/severe mitral regurgitation (65%) or both (5%). In majority of the cases, aortic valve intervention was performed prior to the mitral valve. Mortality rate were 25% for TAVR + TMVR (range 42 days to 10 months), 17% for TAVR + TMViV/ViR (range 13 days to 6 months), 0% for TAViV + TMViV/ViR (range 6-365 days), and 15% for TAVR/ViV + PMVR (range 17 days to 419 days). Significant (more than moderate) paravalvular regurgitation post-procedure was rare.
CONCLUSIONS
CTAMVI appears to confer reasonable clinical outcome. Further large study is warranted to clarify the optimal strategy, procedural details and clinical outcomes in the future.
Topics: Adult; Aged; Aged, 80 and over; Aortic Valve; Cardiac Catheterization; Female; Heart Valve Diseases; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemodynamics; Humans; Male; Middle Aged; Mitral Valve; Prosthesis Design; Recovery of Function; Severity of Illness Index; Transcatheter Aortic Valve Replacement; Treatment Outcome
PubMed: 28862381
DOI: 10.1002/ccd.27256 -
Journal of the American Geriatrics... Dec 2018To summarize evidence on cognitive outcomes after heart valve surgery; secondary aim, to examine whether aortic and mitral valve surgery are associated with different... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
To summarize evidence on cognitive outcomes after heart valve surgery; secondary aim, to examine whether aortic and mitral valve surgery are associated with different cognitive outcomes.
DESIGN
Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review and meta-analysis.
SETTING
Cardiac surgery.
PARTICIPANTS
Individuals undergoing heart valve surgery.
MEASUREMENTS
We searched MEDLINE, EMBASE, and PsycINFO for peer-reviewed reports of individuals undergoing heart valve surgery who underwent pre- and postoperative cognitive assessment. Our initial search returned 1,475 articles, of which 12 were included. Postoperative cognitive results were divided into those from 1 week to 1 month (early outcomes, n = 450) and from 2 to 6 months (intermediate outcomes; n = 722). No studies with longer-term outcomes were identified.
RESULTS
Subjects had moderate early cognitive decline from baseline (Becker mean gain effect size (ES)=-0.39 ± 0.27) that improved slightly by 2 to 6 months (ES=-0.25 ± 0.38). Individuals undergoing aortic valve surgery-who were older on average than those undergoing mitral valve surgery (68 vs 57)-had greater early cognitive decline than those undergoing mitral valve surgery (ES=-0.68 vs -0.12), but both cohorts had similar decline 2 to 6 months postoperatively (ES=-0.27 vs -0.20).
CONCLUSIONS
Heart valve surgery is associated with cognitive decline over the 6 months after surgery, but outcomes beyond 6 months are unclear. These findings highlight the cognitive vulnerability of this population, especially older adults with aortic stenosis. © 2018 American Geriatrics Society and Wiley Periodicals, Inc. J Am Geriatr Soc 66:2327-2334, 2018.
Topics: Aged; Aortic Valve; Aortic Valve Stenosis; Cardiac Surgical Procedures; Cognitive Dysfunction; Humans; Mitral Valve Insufficiency; Risk Factors
PubMed: 30307031
DOI: 10.1111/jgs.15601 -
Hellenic Journal of Cardiology : HJC =... 2023Patients with mitral stenosis (MS) may be predisposed to acute cerebrovascular events (ACE) and peripheral thromboembolic events (TEE). Concomitant atrial fibrillation... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Patients with mitral stenosis (MS) may be predisposed to acute cerebrovascular events (ACE) and peripheral thromboembolic events (TEE). Concomitant atrial fibrillation (AF), mitral annular calcification (MAC) and rheumatic heart disease (RHD) are independent risk factors. Our aim was to evaluate the incidence of ACEs in MS patients and the implications of AF, MAC and RHD on thromboembolic risks.
METHODS
This systematic review was registered on PROSPERO (CRD42021291316). Six databases were searched from inception to 19th December 2021. The clinical outcomes were composite ACE, ischaemic stroke/transient ischaemic attack (TIA) and peripheral TEE.
RESULTS
We included 16 and 9 papers, respectively, in our qualitative and quantitative analyses. The MS cohort with AF had the highest incidence of composite ACE (31.55%; 95% CI 3.60-85.03; I = 99%), followed by the MAC (14.85%; 95% CI 7.21-28.11; I = 98%), overall MS (8.30%; 95% CI 3.45-18.63; I = 96%) and rheumatic MS population (4.92%; 95% CI 3.53-6.83; I = 38%). Stroke/TIA were reported in 29.62% of the concomitant AF subgroup (95% CI 2.91-85.51; I = 99%) and in 7.11% of the overall MS patients (95% CI 1.91-23.16; I = 97%). However, the heterogeneity of the pooled incidence of clinical outcomes in all groups, except the rheumatic MS group, was substantial and significant. The logit-transformed proportion of composite ACE increased by 0.0141 (95% CI 0.0111-0.0171; p < 0.01) per year of follow-up.
CONCLUSION
In the MS population, MAC and concomitant AF are risk factors for the development of ACE. The scarcity of data in our systematic review reflects the need for further studies to explore thromboembolic risks in all MS subtypes.
Topics: Humans; Mitral Valve Stenosis; Ischemic Attack, Transient; Incidence; Brain Ischemia; Stroke; Heart Valve Diseases; Rheumatic Heart Disease; Atrial Fibrillation; Thromboembolism
PubMed: 36041698
DOI: 10.1016/j.hjc.2022.08.002 -
Acta Cardiologica Dec 2022The study aimed to systematically review the existing literature and assess the effects of percutaneous balloon mitral valvuloplasty (PBMV) in patients with mitral... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
The study aimed to systematically review the existing literature and assess the effects of percutaneous balloon mitral valvuloplasty (PBMV) in patients with mitral stenosis and atrial fibrillation (AF) as opposed to sinus rhythm (SR).
METHODS
Eligible studies were identified from six electronic databases before June 2021. The primary outcome was mitral valve area (MVA), and secondary outcomes were hemodynamic measurements, in-hospital complications, and long-term outcomes. Relative risks (RRs) or weighted mean differences (WMDs) with 95% confidence intervals (CIs) were used as effect sizes.
RESULTS
Fifteen studies were included involving 6351 patients. For the primary outcome, the AF group obtained less favourable changes in MVA (WMD: -0.10, 95%CI: -0.14, -0.06) and a significantly smaller postoperative and long-term MVA (WMD: -0.13, 95%CI: -0.18, -0.08 and WMD: -0.10, 95%CI: -0.17, -0.03, respectively) compared to the SR group. For secondary outcome, the AF group was associated with suboptimal outcomes as following (WMD/RR, [95%CI]): higher LAP (1.37, [0.86, 1.87]), more embolism (2.85, [1.44, 5.63]), lower event-free survival (0.89, [0.80, 1.00]), higher incidences of mitral valve replacement (2.20, [1.40, 3.46]), re-PBMV (2.28, [1.63, 3.19]), and mortality (3.28, [2.42, 4.44]). No significant differences were found in other outcomes.
CONCLUSIONS
The currently available evidence suggests that PBMV may be less effective in patients with AF than in those with SR. However, early treatment and appropriate management of AF patients undergoing PBMV may benefit the immediate and long-term outcomes.
Topics: Humans; Mitral Valve Stenosis; Atrial Fibrillation; Treatment Outcome; Progression-Free Survival
PubMed: 34866553
DOI: 10.1080/00015385.2021.1989837