Early Aortic-Valve Replacement in Patients with Asymptomatic Severe Aortic Stenosis with Preserved Left Ventricular Systolic Function: A Systematic Review and Meta-Analysis.

Abstract

Current guidelines recommend routine clinical surveillance for patients with asymptomatic severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF). However, the role of early aortic valve replacement (AVR) as compared with conservative treatment in these patients remains unclear. We systematically searched PubMed, Embase and Cochrane databases to identify studies comparing early AVR versus conservative treatment in asymptomatic patients with severe AS and preserved LVEF. All statistical analyses were performed using R software version 4.3.1 with a random-effects model. Seven studies comprising 2,531 patients with asymptomatic severe AS and preserved LVEF were included, of whom 1,234 (49%) underwent AVR. Median follow-up time was 49.3 months. Early AVR was associated with significantly lower incidence of all-cause (HR 0.51; 95% CI 0.31-0.83) and cardiac mortality (RR 0.51; 95% CI 0.30-0.89). There were no significant differences between early AVR and conservative treatment in terms of sudden death, hospitalization for cardiovascular (CV) causes, stroke, or myocardial infarction (MI). However, upon a subanalysis of randomized controlled trials (RCTs) only, patients undergoing early AVR had lower rates of hospitalization for CV causes (RR 0.41; 95% CI 0.27-0.63) and stroke (RR 0.62; 95% CI 0.40-0.95), with no difference in terms of all-cause mortality, sudden death, MI, or cardiac death. In this meta-analysis, early AVR was associated with reduced rates of all-cause and cardiac mortality, while yielding similar rates of stroke, hospitalization for CV causes, MI, or sudden death in the overall cohort analysis as compared with conservative treatment.