Key result
Early aortic valve replacement fails to reduce all-cause mortality compared to conservative management.
Why the study?
Guidelines recommend AVR in only a select subset of asymptomatic severe AS patients despite poor 4-year survival, leaving the effect of early AVR in asymptomatic patients with preserved LV function uncertain.
Does early aortic valve replacement reduce all-cause mortality compared to conservative therapy in patients with asymptomatic severe aortic stenosis with preserved left ventricular function?
Meta-Analysis (n=2,889)
Does early aortic valve replacement reduce all-cause mortality compared to conservative therapy in patients with asymptomatic severe aortic stenosis with preserved left ventricular function?
Early aortic valve replacement in asymptomatic severe aortic stenosis does not appear to improve overall survival based on high-quality RCT data, but it may significantly reduce heart failure hospitalizations.
Answers are grounded in this paper and cite their sources.
No mortality benefit from early AVR in asymptomatic severe AS per RCT meta-analysis; challenges observational data and leaves open effects on HF events.
Background A quarter of patients with severe aortic stenosis (AS) were asymptomatic, and only a third of them survived at the end of 4 years. Only a select subset of these patients was recommended for aortic valve replacement (AVR) by the current American College of Cardiology/American Heart Association guidelines. We intended to study the effect of early AVR (eAVR) in this subset of asymptomatic patients with preserved left ventricle function. Methods and results We searched PubMed and Embase for randomised and observational studies comparing the effect of eAVR versus conservative therapy in patients with severe, asymptomatic AS and normal left ventricular function. The primary outcome was all-cause mortality. The secondary outcomes were composite major adverse cardiac events (MACE) (study defined), myocardial infarction (MI), stroke, cardiac death, sudden death, the development of symptoms, heart failure hospitalisations and major bleeding. We used GRADEPro to assess the certainty of the evidence. In the randomised controlled trial (RCT) only analysis, we found no significant difference in all-cause mortality between the early aortic intervention group versus the conservative arm (CA) (incidence rate ratio, IRR (CI): 0.5 (0.2 to 1.1), I 2 =31%, p=0.09). However, in the overall cohort, we found mortality benefit for eAVR over CA (IRR (CI): 0.4 (0.3 to 0.7), I 2 =84%, p<0.01). There were significantly lower MACE, cardiac death, sudden death, development of symptoms and heart failure hospitalisations in the eAVR group. We noticed no difference in MI, stroke and major bleeding. Conclusion We conclude that there is no reduction in all-cause mortality in the eAVR arm in patients with asymptomatic AS with preserved ejection fraction. However, eAVR reduces heart failure related hospitalisations and death or heart failure hospitalisations. PROSPERO registration number CRD42022306132.
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Senguttuvan et al. (2024) conducted a meta-analysis in Asymptomatic severe aortic stenosis with preserved left ventricular function (n=2,889). Early aortic valve replacement vs. Conservative therapy (medical therapy alone or wait-and-watch strategy) was evaluated on All-cause mortality (RCT-only analysis) (IRR 0.5, 95% CI 0.2-1.1, p=0.09). Early aortic valve replacement did not significantly reduce all-cause mortality compared to conservative management in the randomized controlled trial analysis (IRR 0.5, 95% CI 0.2-1.1, p=0.09).
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