To bridge or not to bridge with perioperative heparin: a bayesian meta-analysis of thromboembolic and bleeding outcomes in surgical patients with mechanical prosthetic heart valves

Introduction Patients with mechanical heart valves (MHV) require lifelong anticoagulation, which is often interrupted for non-cardiac surgery. Perioperative heparin bridging is commonly used to reduce thromboembolic risk but may increase bleeding, and its net benefit remains uncertain. Notably, no dedicated meta-analysis has directly compared bridging versus no bridging in this population. Purpose To perform a Bayesian meta-analysis to provide probabilistic, clinically actionable estimates of the benefits and risks of perioperative bridging in patients with MHV undergoing surgery. Methods We systematically searched PubMed, Embase, and the Cochrane Library for studies comparing perioperative heparin bridging versus no bridging in patients with MHV undergoing surgery. A Bayesian random-effects meta-analysis was performed, and binary outcomes were synthesized using a binomial-normal hierarchical model to estimate posterior distributions of log odds ratios (log ORs) with corresponding 95% credible intervals (CrIs). Posterior probabilities were calculated to quantify the likelihood and certainty of treatment benefit or harm. Results Three studies comprising 1,298 patients met the inclusion criteria, of whom 724 (55.8%) received bridging therapy. The mean age was 64.2 years. In the Bayesian meta-analysis, bridging therapy was associated with an estimated OR for thromboembolism of 1.37 (95% CrI, 0.33–5.72). The posterior probability of any benefit (OR ≤ 1.0) was 33.3%, and the probability of a clinically meaningful benefit (OR ≤ 0.8) was 23%. The probability of any harm (OR > 1.0) was 66.6%, with a 57.1% probability of clinically meaningful harm (OR > 1.2). For major bleeding, bridging therapy yielded an estimated OR of 1.71 (95% CrI, 0.52–5.64). The posterior probability of any benefit was 17%, and that of a clinically meaningful benefit was 9.3%. In contrast, the probability of any harm was 83%, including a 73.8% probability of clinically meaningful harm. For minor bleeding, the estimated OR was 1.53 (95% CrI, 0.71–3.36). The posterior probability of any benefit was 12%, with a 4.2% probability of clinically meaningful benefit, whereas the probability of any harm was 88%, with a 75% probability of clinically meaningful harm. Conclusions In patients with MHV undergoing surgery, perioperative heparin bridging was not associated with a meaningful probability of thromboembolic benefit and demonstrated a high probability of harm, particularly for major and minor bleeding. Bayesian estimates suggest that bridging is more likely to increase bleeding risk than to provide clinically relevant thromboembolic protection. These findings call into question the routine use of perioperative bridging in this population and highlight the need for individualized risk assessment and higher-quality evidence.