Comparing perioperative heparin bridging strategies in mechanical heart valve patients undergoing surgery: A systematic review and Bayesian meta-analysis

INTRODUCTION: Perioperative heparin bridging in surgical mechanical heart valve (MHV) patients aims to prevent thromboembolism but risks bleeding. Addressing a lack of comparative data, this study synthesizes current literature to evaluate the net clinical outcomes of bridging versus no bridging. PURPOSE: To perform a meta-analysis providing clinically actionable estimates of the benefits and risks of perioperative bridging in surgical MHV patients. METHODS: We systematically searched PubMed, Embase, and the Cochrane Library for studies comparing heparin bridging versus no bridging in surgical MHV patients. We used a Bayesian random-effects meta-analysis to estimate risk ratios (RRs) and 95% credible intervals (95% CrIs). Posterior probabilities were then calculated to assess the treatment benefit or harm. RESULTS: Four studies comprising 1847 patients (64.48% bridged) met the inclusion criteria. The estimated RR for thromboembolism was 1.36 (95% CrI, 0.27 to 6.97), with only a 35.1% posterior probability of risk reduction (RR ≤ 1), suggesting no clear benefit. All-cause mortality estimates were uncertain (RR, 0.68; 95% CrI, 0.12 to 3.90). Conversely, safety endpoints yielded high probabilities of hemorrhagic complications. The RR for major bleeding was 2.04 (95% CrI, 0.81 to 5.14), carrying an 82.5% probability of clinically meaningful harm (RR > 1.33). Minor bleeding showed a similar pattern (RR, 1.53; 95% CrI, 0.61 to 3.93). CONCLUSIONS: Routine perioperative heparin bridging in surgical MHV patients increases bleeding risk without meaningful thromboembolic benefit, supporting a shift toward selective, risk-adapted management. REGISTRATION: PROSPERO identifier no. CRD420261359162.