Reassessing treatment strategies for obstructive prosthetic valve thrombosis: fibrinolysis or urgent surgery?
B L Resende, E Mata, M Castro, S Ribeiro, J Gameiro, A Lourenco, G Costa, L GoncalvesAbstract
Background
Obstructive prosthetic valve thrombosis (PVT) is a rare but life-threatening complication. The optimal first-line therapy remains debated. While surgery has historically been preferred, advances in low-dose, slow-infusion alteplase protocols have improved fibrinolysis outcomes.
Methods
Following a systematic search of five databases, we conducted a systematic review and meta-analysis compared fibrinolysis with urgent surgery for obstructive PVT. The co-primary outcomes were in-hospital all-cause mortality and complete valve function restoration. Secondary outcomes included stroke, systemic embolization, major bleeding, recurrent PVT, and all-cause mortality during follow-up. Data were pooled using random-effects models, with sensitivity and meta-regression analyses.
Results
Across 12 observational studies and 1 randomized controlled trial, 1300 patients (586 fibrinolysis, 714 surgery) were included. No significant difference was observed in in-hospital mortality (RR 0.62, CI 0.32–1.21; I²=57%). However, fibrinolysis was associated with lower complete valve function restoration (RR 2.02, CI 1·25–3.27; I²=70%) and higher risks of stroke (RR 3.57, CI 1.36–9.34; I²=0%), systemic embolization (RR 3.88, CI 1.16–13.0; I²=0%), and recurrent PVT (RR 2.46, CI 1.26–4.82; I²=58%). No differences were found in major bleeding or all-cause mortality during follow-up. Sensitivity analyses restricted to alteplase-based regimens favored fibrinolysis, showing lower in-hospital mortality (RR 0.12, CI 0.04–0.40; I²=0%) with efficacy comparable to surgery.
Conclusion
Surgery offers definitive clot removal with higher immediate success and fewer embolic or recurrent events. Low-dose alteplase protocols achieve outcomes approaching surgery with improved safety. Given the low certainty of available evidence, treatment should be individualized according to patient risk profile, surgical expertise, and institutional resources.For image description, please refer to the figure legend and surrounding text.