AIMS
This study compares PMA and OMT in terms of mortality, recurrence, and hospital stay through a systematic review and meta-analysis.

METHODS AND RESULTS
We conducted a comprehensive systematic review and meta-analysis in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A systematic search was performed across PubMed, Scopus, Embase, Cochrane Library, and Web of Science databases from inception through August 2025. We included observational and comparative studies that evaluated patients with TVE undergoing either PMA (using systems such as AngioVac or AlphaVac) or OMT. The primary efficacy endpoint was all-cause mortality. Secondary endpoints included endocarditis recurrence and median hospital length of stay (LOS). Statistical analysis was conducted using R software (version 4.2.3). Risk Ratios (RR) and Mean Differences (MD) were calculated using a random-effects model. Heterogeneity was assessed using the I2 statistic, and a leave-one-out sensitivity analysis was performed to identify sources of statistical variance.

Results

Four comparative studies were identified, encompassing a substantial cohort of 24,993 patients (634 in the PMA group and 24,359 in the OMT group). In the initial pooled analysis, all-cause mortality showed no statistically significant difference between the two strategies (RR: 0.83; 95% CI: 0.43–1.61; p=0.09;I2=53.6%). However, the results were markedly influenced by a single large-scale study. A leave-one-out sensitivity analysis excluding the El Dalati (2024) cohort eliminated statistical heterogeneity (I2=0%) and revealed a significant survival benefit favoring PMA (RR: 0.60; 95% CI: 0.41–0.89; p=0.012). Regarding the risk of endocarditis recurrence, no significant difference was observed between PMA and OMT (RR: 1.22; 95% CI: 0.81–1.83; p=0.60; I2=0%). The median length of stay was numerically higher in the PMA group, but this did not reach statistical significance and was characterized by high heterogeneity (MD: 5.91 days; 95% CI: -2.26 to 14.07; p=0.042; I2 =77.3%), likely reflecting the complexity of patients selected for procedural intervention.

CONCLUSIONS
 This meta-analysis, representing the largest pooled cohort to date, suggests that percutaneous mechanical aspiration is a safe and potentially superior alternative to medical therapy alone for tricuspid valve endocarditis. While the primary analysis was neutral, sensitivity analysis suggests that PMA may significantly reduce all-cause mortality in selected populations. The lack of increased recurrence rates is encouraging for the adoption of this technology. However, the high heterogeneity in length of stay and the influence of large observational datasets underscore the urgent need for randomized controlled trials to definitively establish the role of PMA in the standard of care for TVE.