Eur J Cardiothorac Surg 2009;35:1111-1112. doi:10.1016/j.ejcts.2009.02.045
Copyright © 2009, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Reply to Castelvecchio et al.
Patrick Kleina,
Jeroen J. Baxb,
Robert J.M. Klautza,*
a Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
b Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
Received 23 February 2009;
accepted 24 February 2009.
* Corresponding author. Address: Department of Cardiothoracic Surgery, Leiden University Medical Center, PO BOX 9600, 2300 RC Leiden, The Netherlands. Tel.: +31 71 5264022l; fax: +31 71 5266965. (Email: r.j.m.klautz{at}lumc.nl).
Key Words: Left ventricular reconstruction surgery • Aneurysmectomy • Surgical ventricular restoration • Dor procedure • Ischemic heart disease • Heart failure
We thank the editor for the opportunity to respond to the Letter to the Editor by Castelvecchio et al. [1] and appreciate their critical appraisal of our article Early and late outcome of left ventricular reconstruction surgery in ischemic heart disease: a systematic review of the literature
[2]. We performed this systematic review of the literature on outcome after left ventricular reconstruction surgery by a MEDLINE database search combined with a manual search of major cardiothoracic and cardiology journals (January 1980 to January 2005) and found a weighted average early mortality of 6.9% (62 studies; 12,331 patients). Cumulative 1-, 5- and 10-year survival were 88.5%, 71.5% and 53.9%, respectively. Endoventricular reconstruction showed a reduced risk for both early (RR = 0.79, p
< 0.005) and late (RR = 0.67, p
< 0.001) mortality compared to the linear repair (early: RR = 1.38, p
< 0.001; late: RR = 1.83, p
< 0.001). Early and late mortality were mainly cardiac in origin, with as predominant cause heart failure in respectively 49.7% and 34.5% of the cases. Concomitant CABG significantly decreased late mortality (RR = 0.28, p
< 0.001) without increasing early mortality (RR = 1.018, p
= 0.858). Concomitant mitral valve surgery showed both an increased risk for early (RR = 1.57, p
= 0.001) and late mortality (RR = 4.28, p
< 0.001). A pooled analysis, when well designed and appropriately performed, is a powerful tool to combine in a single conclusion the results of different studies conducted on the same topic. Random effect models were used to control for within-study and between-study variability (random effects modeling). In addition, meta-regression analysis was used to adjust for the influence of patient demographics and prognostic indicators that co-varied with the dependent variable. Despite the advantages of a pooled analysis, such as increased statistical power of a comparison and improved estimation of the effect of a treatment, there are several limitations of our analysis. Publication bias may have influenced our results, since observational studies with a poor outcome may not have been published in full-length papers. Second and most important, surgical techniques and approaches have improved over time, which affects the current results. Third, since to date no prospectively randomized controlled trials have been published concerning LV reconstruction surgery, all studies included in this analysis were observational reports. Therefore, we agree with Castelvecchio et al. that biases limit the results of our systematic review of the literature.
References
- Castelvecchio S, Ranucci M, Menicanti L. The role of surgical technique in determining the outcome of left ventricular reconstruction: a difficult assessment. Eur J Cardiothorac Surg 2009;35:1111.[Free Full Text]
- Klein P, Bax JJ, Shaw LJ, Feringa HHH, Versteegh MIM, Dion RAE, Klautz RJM. Early and late outcome of left ventricular reconstruction surgery in ischemic heart disease. Eur J Cardiothorac Surg 2008;34:1149-1157.[Abstract/Free Full Text]
