Key result
Initial AVR shows no 5-year survival benefit over watchful waiting in asymptomatic severe AS.
Why the study?
Does initial aortic valve replacement improve postoperative survival compared to eventual aortic valve replacement after watchful waiting in asymptomatic severe aortic stenosis patients?
Observational (n=663)
Yes
Does initial aortic valve replacement improve postoperative survival compared to eventual aortic valve replacement after watchful waiting in asymptomatic severe aortic stenosis patients?
In asymptomatic severe aortic stenosis, eventual AVR after watchful waiting yields similar postoperative survival to initial AVR overall, but initial AVR may be beneficial for patients with Vmax ≥4.5 m/s.
Supports watchful waiting in asymptomatic severe AS; leaves open optimal timing pending randomized confirmation.
BACKGROUND: There is no large-scale study comparing postoperative mortality after aortic valve replacement (AVR) for asymptomatic severe aortic stenosis (AS) between initial treatment with AVR vs. eventual AVR after conservative management. METHODS AND RESULTS: We analyzed data from a multicenter registry enrolling 3,815 consecutive patients with severe AS. Of 1,808 asymptomatic patients, 286 patients initially underwent AVR (initial AVR group), and 377 patients were initially managed conservatively and eventually underwent AVR (AVR after watchful waiting group). Mortality after AVR was compared between the 2 groups. Subgroup analysis according to peak aortic jet velocity (Vmax) at diagnosis was also conducted. There was no significant difference between the 2 groups in 5-year overall survival (OS; 86.0% vs. 84.1%, P=0.34) or cardiovascular death-free survival (DFS; 91.3% vs. 91.1%, P=0.61), but on subgroup analysis of patients with Vmax ≥4.5 m/s at diagnosis, the initial AVR group was superior to the AVR after watchful waiting group in both 5-year OS (88.4% vs. 70.6%, P=0.003) and cardiovascular DFS (91.9% vs. 81.7%, P=0.023). CONCLUSIONS: Asymptomatic severe AS patients who underwent AVR after watchful waiting had a postoperative survival rate similar to those who initially underwent AVR. In a subgroup of patients with Vmax ≥4.5 m/s at diagnosis, however, the AVR after watchful waiting group had worse postoperative survival rate than the initial AVR group.
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Miyake et al. (2018) conducted an observational in Asymptomatic severe aortic stenosis (n=663). Initial aortic valve replacement vs. Aortic valve replacement after watchful waiting was evaluated on 5-year overall survival (p=0.34). Initial aortic valve replacement resulted in a similar 5-year overall survival rate compared to aortic valve replacement after watchful waiting in patients with asymptomatic severe aortic stenosis (86.0% vs. 84.1%, P=0.34).
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