Early Versus Deferred Aortic Valve Intervention in Asymptomatic Severe Aortic Stenosis

Background: The optimal timing of aortic valve intervention in asymptomatic severe aortic stenosis (AS) remains debated. Contemporary randomized trials have evaluated early surgical or transcatheter aortic valve intervention versus conservative surveillance, but the absolute clinical benefit and number needed to treat (NNT) remain incompletely defined. Research Question: Among adults with asymptomatic severe AS, what is the absolute clinical benefit of early aortic valve intervention compared with conservative surveillance or deferred intervention? Methods: We performed a meta-analysis of trials comparing early aortic valve intervention with conservative surveillance or deferred intervention in adults with asymptomatic severe AS. Pubmed, OvidSP and Cochrane Central were the databases searched. The primary analysis pooled absolute risk differences (RDs) using random-effects models to estimate NNT. The primary outcome was the trial-defined composite clinical endpoint. All data analysis was done on RStudio. PROSPERO ID: CRD420261414536 Results: Four randomized trials comprising 1,427 patients were included: RECOVERY, AVATAR, EARLY TAVR, and EVOLVED. Early intervention significantly reduced trial-defined composite clinical events compared with conservative/deferred management (pooled RD, –16.7%; 95% CI, –29.4% to –3.9%; I 2 =55.7%), corresponding to an NNT of 7. Early intervention also reduced heart failure/cardiovascular/AS-related hospitalization (pooled RD, –16.5%; 95% CI, –24.4% to –8.5%; I 2 =37.6%), corresponding to an NNT of 7. Effects on all-cause death (RD, –6.9%; 95% CI, –22.8% to 8.9%; I 2 =72.1%), stroke (RD, –2.2%; 95% CI, –5.0% to 0.6%; I 2 =0.0%), myocardial infarction (RD, –4.0%; 95% CI, –25.3% to 17.3%; I 2 =0.0%), and thromboembolic complications (RD, –1.7%; 95% CI, –45.3% to 42.0%; I 2 =41.0%) were directionally favorable but statistically uncertain. Conclusion: In randomized evidence among patients with asymptomatic severe AS, early aortic valve intervention was associated with clinically meaningful absolute reductions in composite adverse events and heart failure/cardiovascular/AS-related hospitalization, with an NNT of approximately 7 for both outcomes. Effects on mortality, stroke, myocardial infarction, and thromboembolic complications were directionally favorable but uncertain. These findings support individualized early intervention discussions based on absolute benefit while highlighting the need for longer-term data to clarify survival and procedural trade-offs.