International journal of cardiology, 11 2 2025, Pages 133269 Early aortic valve replacement versus conservative management in asymptomatic severe aortic stenosis: Meta-analysis of time-to-event data of randomized controlled trials. Jacquemyn X, Sá MP, Marín-Cuartas M, Bax JJ, Borger MA, Clavel MA, Pibarot P, Généreux P, Sultan I
Background
Current guidelines recommend aortic valve replacement (AVR) for symptomatic patients with severe aortic stenosis (AS), but the optimal timing for intervention in asymptomatic patients is still debated. Recent randomized controlled trials (RCTs) have offered new insights, prompting a reevaluation of the potential benefits of early AVR.
Methods
A systematic review and pooled meta-analysis of Kaplan-Meier-derived reconstructed time-to-event data of RCTs published by November 2024 was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. Outcomes were derived from the primary endpoints of the included studies, with the main analysis focusing on all-cause mortality, cardiovascular mortality, and heart failure hospitalization.
Results
Four randomized controlled trials, involving 1427 patients, were included. The early AVR group demonstrated a significant reduction in all-cause mortality (hazard ratio [HR] = 0.72, 95 % confidence interval [CI] 0.53-0.97, p = 0.031), cardiovascular mortality (HR = 0.56, 95 % CI 0.36-0.89, p = 0.014), and heart failure hospitalization (HR = 0.31, 95 % CI 0.18-0.53, p < 0.001). No significant interaction effects between surgical AVR and transcatheter AVR were observed. Additionally, in the conservative management group, the conversion to AVR was substantial, with a median time to conversion of 13.4 months. The cumulative conversion rates were 42.8 % (95 % CI 38.6 %-46.7 %) at 1 year, 82.3 % (95 % CI 78.6 %-85.3 %) at 3 years, and 94.9 % (95 % CI 91.4 %-96.9 %) at 5 years.
Conclusion
Early AVR in asymptomatic patients with severe AS is associated with a significant reduction in all-cause mortality, cardiovascular mortality, and heart failure hospitalization compared to conservative management.
