Asymptomatic Aortic Stenosis: A Complex Decision

Asymptomatic severe aortic stenosis continues to pose a significant challenge when it comes to clinical decision-making, often due to the difficulty in identifying symptoms. When this condition is symptomatic or oligosymptomatic, it is associated with increased rates of hospitalization and mortality.

While current guidelines recommend valve replacement in cases of impaired ventricular function, available reports are not definitive regarding its implementation.

Researchers conducted a meta-analysis that included four randomized studies (EARLY TAVR, EVoLVeD, AVATAR, and RECOVERY), with a total of 1427 patients. Of these, 719 underwent early aortic valve replacement through surgical or transcatheter aortic valve replacement (SAVR or TAVR), while the rest underwent clinical follow-up (CF) alone.

Read also: 1-Year Outcomes of US TAVR Registry with 5th Generation Balloon Expandable Valves.

With an average follow-up of four years, TAVR demonstrated a significant reduction in the rates of hospitalization due to cardiovascular causes or heart failure (combined rate: 14.6% vs. 31.9%; hazard ratio [HR]: 0.40; 95% confidence interval [CI]: 0.30–0.53; I² = 4%; p < 0.01) and in the incidence of stroke (combined rate: 4.5% vs. 7.2%; HR: 0.62; 95% CI: 0.40–0.97; I² = 0%; p = 0.03). However, there were no significant differences in all-cause mortality (combined rate: 9.7% vs. 13.7%; HR: 0.68; 95% CI: 0.40–1.17; I² = 61%; p = 0.17) or cardiovascular mortality (combined rate: 5.1% vs. 8.3%; HR: 0.67; 95% CI: 0.35–1.29; I² = 50%; p = 0.23). It is worth noting that the studies analyzed were highly heterogeneous.

Conclusion

In this meta-analysis of four randomized studies, early aortic valve replacement was associated with a significant reduction in hospitalization rates due to cardiovascular causes or heart failure, as well as in the incidence of stroke. However, there were no differences in all-cause mortality or cardiovascular mortality compared to clinical follow-up.

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

Reference: Philippe Généreux, et al. JACC article in press.