Coronary microvascular dysfunction in patients undergoing transcatheter aortic valve implantation: A systematic review and meta-analysis.
完整摘要 · 中文译文
背景：冠状动脉微血管功能障碍（CMD）是重度主动脉瓣狭窄的并发症。经导管主动脉瓣植入术（TAVI）后其患病率及预后意义研究不足，TAVI术后微血管指标的变化轨迹亦研究不足。 目的：本研究旨在确定CMD的合并患病率、诊断方式的影响、TAVI术后冠状动脉血流储备（CFR）及微血管阻力变化，以及基线CMD对接受TAVI的重度主动脉瓣狭窄患者主要不良心血管事件（MACE）的预后影响。 方法：检索2010年1月至2025年12月间五个数据库，纳入涉及接受TAVI的重度主动脉瓣狭窄成人患者且通过导丝热稀释法、血管造影衍生指标、多普勒测量或负荷心脏磁共振评估CMD的研究。分别使用纽卡斯尔-渥太华量表和GRADE评估偏倚风险和证据确定性。随机效应荟萃分析（DerSimonian-Laird）合并CMD患病率（按诊断方式分层）、CFR变化（均数差；前后设计）和预后风险比（HR）。微血管阻力变化采用叙述性综合。方案前瞻性注册（PROSPERO：CRD42025143775）并按PRISMA 2020指南报告。 结果：共分析11项原始研究，其中10项（n = 1,212）纳入患病率分析。另1项研究（n = 126）仅纳入敏感性分析。CMD患病率为46.8%（95% 置信区间[CI] [34.0, 59.9]；I2 = 72%）和38.4%（95% CI [35.3, 41.7]；I2 = 0%），分别在使用基于导丝的热稀释（k = 6，n = 324）和血管造影（k = 4，n = 888）指标评估时。TAVI术后CFR增加的合并平均差为+0.49（95% CI [+0.27, +0.71]；I2 = 72%；k = 5，n = 103对配对观测）。微血管阻力的降低仅限于压力-流速和储备比指标，绝对最小微血管阻力未发生变化（k = 4，n = 85）。MACE的HR为3.22（95% CI [0.98, 10.60]；I2 = 78%；k = 2，n = 585）。显著的异质性反映了非等同的CMD定义。 结论：TAVI术前CMD的患病率受诊断方法的影响。CFR在TAVI后趋于改善，可能归因于静息需求降低而非结构修复。由于研究数量有限、CMD定义各异以及HR计算方式不兼容，CMD-MACE关联应被视为假设生成性。需要采用标准化CMD定义的前瞻性多中心研究。
完整摘要 · 英文原文
BACKGROUND: Coronary microvascular dysfunction (CMD) is a complication of severe aortic stenosis. Its prevalence after transcatheter aortic valve implantation (TAVI) and prognostic significance are understudied, as are the post-TAVI trajectories of microvascular indices. AIMS: The aims of this study were to determine the pooled prevalence of CMD, the influence of the diagnostic modality, the post-TAVI coronary flow reserve (CFR) and microvascular resistance changes, and the prognostic impact of baseline CMD on major adverse cardiovascular events (MACE) in patients with severe aortic stenosis undergoing TAVI. METHODS: Five databases were searched from January 2010 to December 2025 for studies involving adults with severe aortic stenosis undergoing TAVI in which CMD was assessed by wire-based thermodilution, angiography-derived indices, Doppler measurements, or stress cardiac magnetic resonance. The risk of bias and certainty of evidence were assessed using the Newcastle-Ottawa Scale and GRADE, respectively. Random-effects meta-analyses (DerSimonian-Laird) pooled CMD prevalence (stratified by modality), CFR change (mean difference; before-after design), and prognostic hazard ratios (HRs). Change in microvascular resistance was synthesized narratively. The protocol was prospectively registered (PROSPERO: CRD42025143775) and reported per the PRISMA 2020 guidance. RESULTS: Eleven primary studies were analyzed, 10 of which (n = 1,212) contributed to the prevalence analyses. An additional study (n = 126) was included in the sensitivity analyses only. CMD prevalence was 46.8% (95% confidence interval [CI] [34.0, 59.9]; I2 = 72%) and 38.4% (95% CI [35.3, 41.7]; I2 = 0%) when assessed using wire-based thermodilution (k = 6, n = 324) and angiographic (k = 4, n = 888) indices, respectively. CFR increased post-TAVI by a pooled mean difference of +0.49 (95% CI [+0.27, + 0.71]; I2 = 72%; k = 5, n = 103 paired observations). Reductions in microvascular resistance were confined to pressure-to-velocity and reserve ratio indices, and absolute minimal microvascular resistance was unchanged (k = 4, n = 85). The HR for MACE was 3.22 (95% CI [0.98, 10.60]; I2 = 78%; k = 2, n = 585). Substantial heterogeneity reflected non-equivalent CMD definitions. CONCLUSION: The prevalence of CMD pre-TAVI is influenced by the diagnostic method. CFR tends to improve after TAVI, likely due to reduced resting demand rather than structural repair. The CMD-MACE association should be viewed as hypothesis-generating due to limited studies, varied CMD definitions, and incompatible HR calculations. Prospective multicenter studies with standardized CMD definitions are required.
摘要 待译
BACKGROUND: Coronary microvascular dysfunction (CMD) is a complication of severe aortic stenosis. Its prevalence after transcatheter aortic valve implantation (TAVI) and prognostic significance are understudied, as are the post-TAVI trajectories of microvascular indices.…