Mechanical versus bioprosthetic valves for tricuspid valve replacement in Chinese patients: a systematic review and...

Tricuspid valve replacement (TVR) is a critical intervention for severe tricuspid valve disease but carries high perioperative mortality. The optimal choice between mechanical and bioprosthetic valves remains controversial, and large-sample evidence specific to the Chinese population is lacking. This study aimed to systematically evaluate the clinical efficacy and safety of mechanical versus bioprosthetic valves in Chinese patients undergoing TVR.

PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang Data, VIP (VIP Database), Chinese Biomedical Literature Database (CBM), and the Chinese Medical Journal Database were searched from inception to December 31, 2025. Eligible study types included randomized controlled trials, prospective or retrospective cohort studies, and case-control studies comparing mechanical and bioprosthetic valves in Chinese TVR patients; case reports, reviews, and conference abstracts were excluded. Participants were Chinese patients (including China's mainland, Hong Kong, Macau, and Taiwan) undergoing TVR. The intervention of interest was TVR with a mechanical prosthesis versus a bioprosthesis. Risk of bias for cohort studies was assessed using the Newcastle-Ottawa Scale. Meta-analysis was performed with Review Manager 5.4.1, calculating relative risks for dichotomous outcomes and hazard ratios (HRs) for survival data. A fixed-effect model was used when I²<50%; otherwise, a random-effects model was applied.

Eight retrospective cohort studies (1,504 patients: 537 mechanical, 967 bioprosthetic) were included. No statistically significant differences emerged between mechanical and bioprosthetic valves in early mortality [risk ratio (RR) 0.70, 95% confidence interval (CI): 0.48-1.02, P=0.06], long-term survival (HR 1.02, 95% CI: 0.57-1.84, P=0.94), or reoperation rate (RR 1.12, 95% CI: 0.61-2.05, P=0.72). Mechanical valves were associated with significantly higher risks of thromboembolic events (RR 2.09, 95% CI: 1.06-4.13, P=0.03) and bleeding events (RR 4.89, 95% CI: 3.12-7.72, P<0.00001). The rate of pacemaker implantation did not differ significantly between groups (RR 0.82, 95% CI: 0.44-1.53, P=0.54).

In Chinese TVR patients, overall early and long‑term survival as well as reoperation rates do not differ significantly between mechanical and bioprosthetic valves when analyzed across heterogeneous populations. However, this finding does not imply that valve type is unimportant for individual patients. However, mechanical valves significantly increase postoperative thromboembolic and bleeding complications. Clinical decision-making should be individualized, considering patient age, life expectancy, anticoagulation adherence, and bleeding risk. For Chinese patients with good life expectancy and reliable anticoagulation access, mechanical valves remain an option; for those with poor adherence or high bleeding risk, bioprosthetic valves may be safer.