Surgery Versus Thrombolytic Therapy for the Management of Left‐Sided Prosthetic Valve Thrombosis Without Hemodynamic Compromise: A Systematic Review and Meta‐Analysis

Abstract

Background The optimal strategy in prosthetic heart valve thrombosis (PVT) remains controversial, with no randomized trials and conflicting observational data. We performed a systematic review and meta‐analysis of evidence comparing systemic thrombolysis and cardiac surgery in PVT. Methods and Results We searched PubMed, the Cochrane Library, and Embase for studies on treatment strategies in patients with left‐sided PVT since 2000. The primary outcome was death, and the secondary outcomes were major bleeding and thromboembolism during follow‐up (International Prospective Register of Systematic Reviews No. CRD42022384092). We identified 2298 studies, of which 16 were included, comprising 1389 patients with PVT (mean age, 50.4±9.3 years; 60.0% women). Among them, 67.2% were New York Heart Association stage III/IV at admission. Overall, 48.1% were treated with systemic thrombolysis and 51.9% with cardiac surgery. The mortality rate was 10.8% in the thrombolysis group and 15.3% in the surgery group. The pooled risk difference for death with systemic thrombolysis was 1.13 (exact CI, 0.74–1.79; ζ 2 =0.89; P <0.001) versus cardiac surgery. Rates of both transient ischemic attack and non–central nervous system embolism were higher in the thrombolysis group ( P =0.002 and P =0.02, respectively). Treatment success, major bleeding, and stroke were similar between groups. Sensitivity analysis including studies that used low‐dose or slow‐infusion thrombolysis showed that the mortality rate was lower, and treatment success was higher, in patients referred to systemic thrombolysis, with similar rates of other secondary outcomes. Conclusions There is evidence to suggest that thrombolysis might be the preferred option for the management of PVT without cardiogenic shock, pending future randomized controlled trials or larger observational studies.