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Original research
Percutaneous mitral commissurotomy versus surgical commissurotomy for rheumatic mitral stenosis: a systematic review and meta-analysis of randomised controlled trials
  1. Achintya Dinesh Singh1,
  2. Agrima Mian2,
  3. Niveditha Devasenapathy3,
  4. Gordon Guyatt4,
  5. Ganesan Karthikeyan5
  1. 1 Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
  2. 2 Oncology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
  3. 3 Indian Institute of Public Health-, Delhi, Gurgaon, India
  4. 4 Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
  5. 5 Cardiology, All India Institute of Medical Sciences, New Delhi, India
  1. Correspondence to Dr Ganesan Karthikeyan, Cardiology, All India Institute of Medical Sciences, New Delhi 110029, India; karthik2010{at}gmail.com

Abstract

Aim Patients with severe mitral stenosis (MS) and their clinicians typically choose percutaneous transvenous mitral commissurotomy (PTMC) over surgical commissurotomy (SC). However, the durability of PTMC relative to SC is uncertain. We compared the efficacy, safety and durability of PTMC with SC for the treatment of MS.

Methods We searched EMBASE, MEDLINE and WHO ICTRP registers for randomised controlled trials (RCTs) comparing PTMC, and open and/or closed mitral commissurotomy. The principal outcomes were rate of re-intervention and symptomatic improvement as inferred from the surrogate measures of immediate postprocedural mitral valve area (MVA), MVA at ≥6 month follow-up, incidence of mitral regurgitation (MR) and restenosis. We calculated weighted mean differences (WMD) for continuous outcomes, relative risks (RR) for binary outcomes and pooled outcomes using random-effects models and assessed the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

Results Seven RCTs with 553 patients proved eligible. Pooled estimates showed no convincing difference in the risk of restenosis or re-intervention (15/100 fewer with PTMC, 95% CI (−20 to +8); quality of evidence: moderate) or in symptoms as inferred from immediate MVA (WMD 0.15, 95% CI (−0.18 to 0.48): very low), from the incidence of postprocedural severe MR (3/100 more with PTMC, 95% CI (−1 to +10): moderate) or from MVA at 30 months.

Conclusion Until data demonstrating convincing superiority of SC over PTMC become available, our results support the current practice of recommending PTMC to young patients with MS and favourable valve morphology, as it is associated with lower peri-procedural morbidity.

PROSPERO registration number PROSPERO 2017 (CRD42017079512).

  • mitral stenosis
  • transcatheter valve interventions
  • cardiac procedures and therapy
  • valvular heart disease
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Footnotes

  • Twitter @drkarthik2010

  • ADS and AM contributed equally.

  • Contributors Study concept, design: GK, ND, GG. Data collection: ADS, AM. Statistical analysis: ND, ADS, AM, GG, GK. Writing the first draft: ADS, AM. Analysis and interpretation of results, critical revision of the manuscript for important intellectual content, approval of final version: GK, ND, ADS, AM, GG.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

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