Early Aortic Valve Replacement in Asymptomatic Severe Aortic Stenosis: A Meta-Analysis of Randomized Controlled Trials

Determining the best time for aortic valve replacement (AVR) in asymptomatic severe aortic stenosis (AS) with preserved left ventricular function remains controversial, as current guidelines recommend waiting until symptoms appear. Recent evidence suggests that early AVR may improve outcomes for select patients. This meta-analysis of randomized controlled trials evaluated the efficacy of early AVR, including surgical and transcatheter approaches, versus conservative management in asymptomatic severe AS. We systematically searched PubMed, Embase, CENTRAL, and ClinicalTrials.gov to identify eligible trials. The outcomes of interest included all-cause mortality, unplanned hospitalization, stroke, as well as the composite endpoint of each trial, which was derived from combinations of these outcomes. Four trials involving 1,427 patients were included. Early AVR significantly reduced the risk of unplanned hospitalizations (HR 0.42, 95% CI 0.33 to 0.53, p <0.001, I² = 0%). Although there was a trend towards reduced all-cause mortality, it did not reach statistical significance (HR 0.76, 95% CI 0.48 to 1.21, I² = 42%). Stroke also trended lower with early AVR (HR 0.63, 95% CI 0.40 to 1.00, p = 0.05, I² = 0%). In conclusion, these findings indicate that early AVR may provide clinical benefits by reducing adverse events in asymptomatic severe AS, in particular unplanned rehospitalization, suggesting that early AVR could be beneficial and should be considered in future guideline revisions.