Thrombolytic therapy versus cardiac surgery for left-sided prosthetic heart valve thrombosis: A systematic review and meta-analysis

Introduction The optimal treatment of prosthetic heart valve thrombosis (PVT) remains vigorously debated in international guidelines. The present study was designed to compare the efficacy and safety of thrombolytic therapy and surgery in left-sided PVT, incorporating recent data to inform clinical decision-making. Methods This study is a systematic review with meta-analysis. We searched PubMed, Scopus, and Embase up to Jun 30, 2025. Eligible studies were those reporting treatment strategies and outcomes of patients with left-sided PVT. The primary outcome was treatment success (survival for surgery; complete or partial improvement of valve function and hemodynamic success not requiring surgery after thrombolysis). Results 114 studies were included, representing 6514 patients with 6744 PVT episodes. The success rate in both treatment groups was the same: 83.9% (95% CI: 82.2–85.4; I 2 = 19.8%) for thrombolysis versus 85.1% (95% CI: 83.3–86.7; I 2 = 27%) for surgery ( P -value = 0.607). The mortality rate was lower with thrombolysis (8.5%; 95% CI: 7.5–9.8; I 2 = 0%) than surgery (15%; 95% CI: 13.4–16.8; I 2 = 26.3%) (P-value = 0.001). Other secondary outcomes showed no significant differences. In the slow/very slow thrombolytic infusion subgroup analysis, the success rate was 91.4% (95% CI: 87–94; I 2 = 44.9%) and the mortality was 2.1% (95% CI: 1.2–3.3; I 2 = 0%). Conclusions This systematic review suggests that fibrinolytics are a reasonable option alongside surgery for left-sided PVT, with similar success rates and lower mortality. However, due to observational evidence, results should be interpreted cautiously and randomized controlled trials (RCTs) are needed.