Urgent Surgery Compared with Fibrinolytic Therapy for the Treatment of Left-sided Prosthetic Heart Valve Thrombosis: a Systematic Review and Meta-analysis of Observational Studies

Aims: Left-sided prosthetic valve thrombosis (PVT) occurs frequently in developing countries and causes major morbidity and mortality. Fibrinolytic therapy (FT) is most commonly used as treatment, but increases the risk of stroke and bleeding. Urgent surgery may be more efficacious and cause fewer complications. Our aim was to compare the efficacy and safety of urgent surgery and FT for the treatment of left-sided PVT.

Methods And Results: We searched EMBASE and MEDLINE for articles which included at least five patients each treated with surgery and FT. The primary outcome was complete restoration of valve function. Other outcomes were in-hospital death, thrombo-embolism (stroke, transient ischaemic attack, or non-CNS systemic embolism), major bleeding, and recurrence of PVT on follow-up. We calculated odds ratios (ORs) for each outcome and pooled them using a random effects model. We included seven eligible studies with 690 episodes of PVT, 446 treated with surgery, and 244 with FT. There was no significant difference in the occurrence of the primary outcome (86.5 vs. 69.7%, OR 2.53, 95% CI 0.94-6.78, P = 0.066, I(2) = 74%) or death (13.5 vs. 9%, OR 1.95, 95% CI 0.63-5.98, P = 0.244, I(2) = 59%) between the two treatments. However, compared with FT, urgent surgery was associated with significant reductions in thrombo-embolism (1.6 vs. 16%, OR 0.10, 95% CI 0.04-0.24, P < 0.001, I(2) = 0%), major bleeding (1.4 vs. 5%; OR 0.27, 95% CI 0.08-0.98, P = 0.046, I(2) = 0%), and recurrent PVT (7.1 vs. 25.4%; OR 0.25, 95% CI 0.08-0.74, P = 0.013, I(2) = 59%).

Conclusion: Urgent surgery was not superior to FT at restoring valve function, but substantially reduced the occurrence of thrombo-embolic events, major bleeding, and recurrent PVT. In experienced centres, urgent surgery should probably be preferred over FT for treating left-sided PVT, pending the results of randomized controlled trials.