Eficácia da ablação cirúrgica da fibrilação atrial na cardiopatia reumática - revisão sistemática
Eficácia da ablação cirúrgica da fibrilação atrial na cardiopatia reumática - revisão sistemática
Arquivos
Data
2020
Autores
Penha, Bruno Francisco de Almeida
Journal Title
Journal ISSN
Volume Title
Publisher
Instituto Nacional de Cardiologia
Resumo
Introdução: A febre reumática é a principal causa de disfunção valvar em jovens de países subdesenvolvidos e associa-se à fibrilação atrial, que pode tanto piorar os sintomas, quanto o prognóstico dessa cardiopatia. A ablação cirúrgica é uma opção terapêutica para a fibrilação atrial, porém sua eficácia não é bem estabelecida na população reumática. Objetivo: O presente estudo tem como objetivo avaliar a segurança e eficácia, a curto e longo prazo, da ablação cirúrgica da fibrilação atrial na população reumática. Além disso, analisar as taxas de mortalidade e de acidente vascular cerebral até um ano do procedimento. Desenho: Revisão sistemática e metanálise. Métodos: Realizou-se busca sistemática e ampla em nove bancos de dados, em agosto de 2019, identificando ensaios clínicos randomizados e estudos de coorte que compararam a eficácia da ablação cirúrgica da fibrilação atrial e a cirurgia valvar mitral isolada nos pacientes reumáticos. Dados foram coletados e analisados de acordo com desfechos clínicos pré-estabelecidos. Resultados: Sete artigos foram incluídos, sendo cinco ensaios clínicos randomizados e dois estudos de coorte, totalizando 2011 pacientes. Observou-se redução da incidência de fibrilação atrial em até 12 meses após ablação cirúrgica (RR 0,29, IC 95% [0,14-0,61], I² = 91%, p= 0,001), com elevada qualidade de evidência. Não houve diferença significativa nos desfechos de segurança até 30 dias como mortalidade e reabordagem cirúrgica por sangramento ou tamponamento, porém parece ter aumentado a necessidade de implante de marca-passo definitivo (RR 2,2 IC [1,13-4,27], I²=0%, p= 0,02), com baixa qualidade de evidência. Além disso, reduziu-se a mortalidade geral em 12 meses (RR 0,40, IC 95% [0,31-0,51], I²= 32%, p< 0,00001), a incidência de acidente vascular cerebral em 12 meses (RR 0,51, IC 95% [0,33-0,79], I² = 26%, p=0,002) e a incidência de fibrilação atrial após um ano (RR 0,41, IC 95% [0,36-0,47], I²= 41%, p< 0,00001), com baixa, moderada e muito baixa qualidade de evidência, respectivamente. Conclusão: A ablação cirúrgica da fibrilação atrial parece reduzir a incidência de arritmia até um ano do procedimento, com possibilidade de aumentar a necessidade de implante de marca-passo definitivo. No entanto, não há evidências fortes de redução da mortalidade geral, de acidente vascular cerebral ou que a eficácia da ablação seja duradoura. Novos estudos são necessários para melhor estabelecer os resultados de eficácia, principalmente a longo prazo na população reumática.
Introduction: Rheumatic fever is the main cause of valve dysfunction in young adults from underdeveloped countries and is associated with atrial fibrillation, which can both worsen the symptoms and the prognosis of this cardiopathy. Surgical ablation is a therapeutic option for atrial fibrillation, but its efficacy is not well established in the rheumatic population. Objective: The present study aims to evaluate the safety and efficacy, in the short and long term, of surgical ablation of atrial fibrillation in the rheumatic population. In addition, analyze mortality and stroke rates within one year of the procedure. Design: Systematic review and meta analysis. Methods: The authors performed systematic and extensive electronic searches in nine databases in August 2019, identifying randomized clinical trials and cohort studies that compared the efficacy of surgical ablation of atrial fibrillation and isolated mitral valve surgery in rheumatic patients. The authors extracted and analyzed the data according to predefined clinical outcomes. Results: Seven articles were included, with five randomized clinical trials and two cohort studies, including 2011 patients. A reduction in the incidence of atrial fibrillation was observed within 12 months after surgical ablation (RR 0.29, 95% CI [0.14-0.61], I² = 91%, p = 0.001), with high quality of evidence. There was no significant difference in safety outcomes up to 30 days such as mortality and surgical reoperation due to bleeding or cardiac tamponade, but there seems to have been an increased need for permanent pacemaker implantation (RR 2.2 CI [1.13-4.27], I² = 0%, p = 0.02), with low quality of evidence. In addition, there were reductions in overall mortality within 12 months (RR 0.40, 95% CI [0.31-0.51], I² = 32%, p <0.00001), the incidence of stroke within 12 months (RR 0.51, 95% CI [0.33-0.79], I² = 26%, p = 0.002) and the incidence of atrial fibrillation after one year (RR 0.41, 95% CI [0 , 36-0.47], I² = 41%, p <0.00001), with low, moderate and very low quality of evidence, respectively. Conclusion: Surgical ablation of atrial fibrillation seems to reduce the incidence of arrhythmia up to one year after the procedure, with the possibility of increasing the need for permanent pacemaker implantation. However, there is no strong evidence of a reduction in overall mortality, stroke or if the effectiveness of ablation is long lasting. It is important to perform further studies in order to establish efficacy results, especially in the long term in the rheumatic population.
Introduction: Rheumatic fever is the main cause of valve dysfunction in young adults from underdeveloped countries and is associated with atrial fibrillation, which can both worsen the symptoms and the prognosis of this cardiopathy. Surgical ablation is a therapeutic option for atrial fibrillation, but its efficacy is not well established in the rheumatic population. Objective: The present study aims to evaluate the safety and efficacy, in the short and long term, of surgical ablation of atrial fibrillation in the rheumatic population. In addition, analyze mortality and stroke rates within one year of the procedure. Design: Systematic review and meta analysis. Methods: The authors performed systematic and extensive electronic searches in nine databases in August 2019, identifying randomized clinical trials and cohort studies that compared the efficacy of surgical ablation of atrial fibrillation and isolated mitral valve surgery in rheumatic patients. The authors extracted and analyzed the data according to predefined clinical outcomes. Results: Seven articles were included, with five randomized clinical trials and two cohort studies, including 2011 patients. A reduction in the incidence of atrial fibrillation was observed within 12 months after surgical ablation (RR 0.29, 95% CI [0.14-0.61], I² = 91%, p = 0.001), with high quality of evidence. There was no significant difference in safety outcomes up to 30 days such as mortality and surgical reoperation due to bleeding or cardiac tamponade, but there seems to have been an increased need for permanent pacemaker implantation (RR 2.2 CI [1.13-4.27], I² = 0%, p = 0.02), with low quality of evidence. In addition, there were reductions in overall mortality within 12 months (RR 0.40, 95% CI [0.31-0.51], I² = 32%, p <0.00001), the incidence of stroke within 12 months (RR 0.51, 95% CI [0.33-0.79], I² = 26%, p = 0.002) and the incidence of atrial fibrillation after one year (RR 0.41, 95% CI [0 , 36-0.47], I² = 41%, p <0.00001), with low, moderate and very low quality of evidence, respectively. Conclusion: Surgical ablation of atrial fibrillation seems to reduce the incidence of arrhythmia up to one year after the procedure, with the possibility of increasing the need for permanent pacemaker implantation. However, there is no strong evidence of a reduction in overall mortality, stroke or if the effectiveness of ablation is long lasting. It is important to perform further studies in order to establish efficacy results, especially in the long term in the rheumatic population.
Description
Palavras-chave
Rheumatic disease, Atrial fibrilation, Surgical ablation, Doença reumática, Fibrilação atrial, Ablação cirúrgica
Citação
Penha, BFA.Eficácia da ablação cirúrgica da fibrilação atrial na cardiopatia reumática - revisão sistemática. Rio de Janeiro. Dissertação [Mestrado Profissional em Avaliação de Tecnologias em Saúde] - Instituto Nacional de Cardiologia; 2020.