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BACKGROUND: Obstructive prosthetic valve thrombosis (PVT) is a life-threatening complication. The first-line therapy remains uncertain. While surgery has historically been preferred, advances in low-dose, slow-infusion fibrinolysis protocols have improved outcomes.

OBJECTIVES: To evaluate the efficacy and safety of fibrinolytic therapy versus urgent valve surgery in PVT.

METHODS: Following a systematic search of 5 databases, a meta-analysis compared fibrinolysis with urgent valve surgery for obstructive PVT. The primary outcomes were in-hospital all-cause mortality and complete restoration of valve function. Secondary outcomes included stroke, systemic embolism, major bleeding, recurrent PVT, and all-cause mortality during follow-up. Data were pooled as risk ratio (RR) using random-effects models, with sensitivity and meta-regression analyses.

RESULTS: Across 12 observational studies and 1 randomized controlled trial, 1300 patients (fibrinolysis/surgery: 714/586) were included. No significant difference was observed in in-hospital mortality (RR: 0.59 [0.27-1.30]; I2=57.1%). However, fibrinolysis was associated with lower complete restoration of valve function (RR: 0.82 [0.70-0.96]; I2=71.6%) and higher risks of stroke (RR: 3.19 [1.30-7.85]; I2=0%), systemic embolism (RR: 3.88 [1.44-10.4]; I2=0%), and recurrent PVT (RR: 2.44 [1.18-5.05]; I2=58.3%). 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 [0.05-0.29]; I2=0%), consistent with meta-regression findings, and efficacy comparable to surgery.

CONCLUSION: Our study suggests that surgery offers higher immediate success with fewer embolic or recurrent events. However, contemporary alteplase protocols may be associated with improved safety outcomes relative to surgery, with no apparent loss of efficacy. Given the low certainty of available evidence, treatment should be individualized according to patient risk profile, and institutional resources.

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