Tricuspid valve infective endocarditis (TVIE) accounts for approximately 5% to 10% of all cases of infective endocarditis. Surgical treatment remains the standard therapy in cases with persistent bacteremia, septic emboli, vegetations larger than 2 cm, or severe tricuspid regurgitation, although it is associated with risks such as bleeding, reoperation, and operative mortality.
Percutaneous mechanical aspiration (PMA) allows reduction of vegetation burden in patients with high surgical risk or contraindications to surgery. In order to compare both strategies, the authors conducted a systematic review and meta-analysis of the clinical outcomes of PMA versus surgery in TVIE.
The primary endpoint was all-cause mortality (in-hospital, at 30 days, and at 1 year), while secondary endpoints included length of hospital stay and the rate of readmission due to endocarditis.
A systematic search was performed through July 2025, identifying 10 retrospective comparative studies conducted in the United States evaluating PMA versus surgical treatment in tricuspid endocarditis.
Percutaneous Mechanical Aspiration vs Surgery in Tricuspid Valve Endocarditis: Impact on Mortality and Clinical Outcomes
A total of 6,035 patients were analyzed, of whom 974 were treated with PMA and 5,061 with surgery. The patients had a mean age of approximately 33–35 years and a high prevalence of intravenous drug use, present in more than 70% of cases. Significant tricuspid regurgitation, septic emboli, and septic shock were frequent findings.
Percutaneous aspiration (often performed using aspiration systems such as AngioVac) was mainly used in patients considered to be at high surgical risk or with contraindications to surgery, whereas surgical intervention allowed valve repair or replacement and definitive treatment of the infectious focus.
In the analysis of in-hospital mortality, no significant differences were observed between the two strategies (RR 1.07; 95% CI 0.32–3.57; p=0.91). In contrast, 30-day mortality was significantly higher in the group treated with percutaneous aspiration (RR 2.71; 95% CI 1.53–4.82; p<0.001).
Despite this finding, 1-year mortality showed no significant differences between the two strategies (RR 1.13; 95% CI 0.72–1.77; p=0.60). A significantly shorter hospital stay was observed with percutaneous aspiration, with a mean difference of −7.0 days (95% CI −12.96 to −1.05; p=0.03), and the risk of readmission due to endocarditis was similar between both groups (RR 0.82; 95% CI 0.36–1.85; p=0.63).
Conclusion
In summary, in this meta-analysis including patients with tricuspid endocarditis, percutaneous mechanical aspiration was associated with a shorter length of hospital stay, whereas surgical treatment showed better short-term survival, particularly at 30 days. No differences were observed in 1-year mortality or in the rates of readmission for endocarditis between the two strategies.
Since the available evidence derives exclusively from observational studies with moderate to high risk of bias, the authors conclude that randomized clinical trials are needed to more precisely define the relative role of these therapeutic strategies.
Original Title: Percutaneous Mechanical Aspiration Versus Surgical Management of Tricuspid Valve Endocarditis: A Systematic Review and Updated Meta-Analysis.
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