Should Early Aortic Valve Replacement Be Indicated in Asymptomatic Severe Aortic Stenosis?

A Meta-Analysis of Randomized Clinical Trials.

The management of aortic stenosis in asymptomatic patients remains a matter of debate. Traditionally, a conservative strategy has been recommended; however, increasing evidence suggests that untreated disease may progress to serious complications. This meta-analysis assessed whether early aortic valve replacement (surgical or transcatheter) offers advantages over conservative management in this population.

The primary endpoint was a composite outcome of all-cause mortality, cardiovascular hospitalization, stroke, and myocardial infarction (MI). Four randomized clinical trials were included (RECOVERY, AVATAR, EVOLVED, and EARLY TAVR) with a total of 1,427 patients: three evaluated surgery (in younger, low-risk populations) and one TAVR (in patients older than 65 years with low-to-intermediate risk). A total of 719 patients were assigned to early intervention and 708 to conservative management. The mean age ranged from 63 to 76 years, with a male predominance (41–73%). Patients had an aortic valve area of 0.6–0.8 cm² and preserved ejection fraction. Median follow-up ranged from 42 to 74 months.

Results showed that early valve replacement significantly reduced the composite outcome (29.2% vs. 53.7%; RR 0.56; 95% CI 0.49–0.64; I²=60%). All-cause mortality was also reduced (10.0% vs. 13.7%; RR 0.74; 95% CI 0.55–0.99; I²=58%), as well as cardiovascular hospitalizations (14.6% vs. 32.5%; RR 0.48; 95% CI 0.39–0.58; I²=26%) and stroke (4.5% vs. 7.2%; RR 0.62; 95% CI 0.40–0.95; I²=0%). No significant differences were found in cardiac-specific mortality (8.3% vs. 16%; RR 0.68; 95% CI 0.40–1.16; I²=65%) or MI (0.6% vs. 4.6%; RR 0.21; 95% CI 0.04–1.19; I²=0%).

Read als: Angioplasty vs Carotid Endarterectomy: Systematic Review and Meta-Analysis of Randomized Clinical Trials.

The meta-regression analysis showed that the benefit of early replacement was smaller in older patients, whereas those with more severe stenosis (higher velocity or gradient) derived greater benefit from intervention. Overall, both surgery and TAVR outperformed conservative management, although the impact varied depending on patient characteristics: in younger patients with advanced stenosis, mortality reduction predominated, while in older and higher-risk patients, the main benefit was a reduction in hospitalizations and nonfatal events.

Conclusion

This meta-analysis demonstrated that early aortic valve replacement (surgical or transcatheter) was superior to conservative management in reducing overall mortality, cardiovascular hospitalizations, and stroke. However, no significant differences were observed in cardiac-specific mortality or MI. While further studies are warranted, these findings support early intervention in selected patients with asymptomatic severe aortic stenosis.

Original Title: Early Aortic Valve Replacement of Asymptomatic Severe Aortic Stenosis: A Meta‐Analysis of Randomized Controlled Trials.

Reference: Qingchun Song, Ruilin Liu, Kai Yang, Xiaokang Tu, Haoyu Tan, Chengming Fan, Xiaoxiao Li. Journal of the American Heart Association. 2025;14:e041283. DOI: 10.1161/JAHA.125.041283.