Aortic Valve Replacement vs Clinical Surveillance in Asymptomatic Severe Aortic Stenosis: A Systematic Review and Meta-Analysis

In this study-level meta-analysis of randomized controlled trials (RCTs) evaluating the effect of early aortic valve replacement (AVR) versus clinical surveillance (CS) in patients with asymptomatic severe aortic stenosis (AS), four RCTs were identified and included for analysis: AVATAR, RECOVERY, EARLY TAVR, EVOLVED. Prespecified outcomes included all-cause and cardiovascular mortality, unplanned cardiovascular or heart failure (HF) hospitalization, and stroke. A total of 1,427 patients (719 in the early AVR group and 708 in the CS group) were included for analysis.  

At an average follow-up time of 4.1 years, early AVR was associated with a significant reduction in unplanned cardiovascular or HF hospitalization (14.6 percent versus 31.9 percent; HR: 0.40; 95 percent CI: 0.30-0.53;P<0.01) and stroke (4.5 percent versus 7.2 percent; HR: 0.62; 95 percent CI: 0.40-0.97;P=0.03). However, no statistically significant differences in all-cause mortality (9.7 percent versus 13.7 percent; HR: 0.68; 95 percent CI: 0.40-1.17;P=0.17) and cardiovascular mortality (5.1 percent versus 8.3 percent; HR: 0.67; 95 percent CI: 0.35-1.29; P=0.23) were observed with early AVR compared with CS. The authors conclude that early AVR is associated with a significant reduction in unplanned cardiovascular or HF hospitalization and stroke, but no difference in all-cause or cardiovascular mortality compared with CS.