Aortic Valve Replacement Versus Clinical Surveillance in Asymptomatic Severe Aortic Stenosis: A Systematic Review and Meta-Analysis

Background

Current guidelines recommend a strategy of clinical surveillance (CS) for patients with asymptomatic severe aortic stenosis (AS) and normal left ventricular ejection fraction.

Objectives

To conduct a study-level meta-analysis of randomized controlled trials (RCTs) evaluating the effect of early aortic valve replacement (AVR) compared with CS in patients with asymptomatic severe AS.

Methods

Studies were quantitatively assessed in a meta-analysis using random effects modeling. Prespecified outcomes included all-cause and cardiovascular mortality, unplanned cardiovascular or heart failure (HF) hospitalization, and stroke. The meta-analysis is registered on the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY 202490002).

Results

Four RCTs were identified, including a total of 1427 patients (719 in the early AVR group and 708 in the CS group). At an average follow-up time of 4.1 years, early AVR was associated with a significant reduction in unplanned cardiovascular or HF hospitalization (pooled rates, 14.6% vs. 31.9%; HR 0.28; 95% CI, (0.17-0.47); I²=0%; p<0.01) and stroke (pooled rates 4.5% vs. 7.2%; HR, 0.62; 95% CI, 0.40-0.97; I²=0%; p=0.03). No differences in all-cause mortality (pooled rates 9.7% vs. 13.7%; HR, 0.68; 95% CI, 0.40-1.17; I²=61%; p=0.17) and cardiovascular mortality (pooled rates 5.1% vs. 8.3%; HR, 0.67; 95% CI, 0.35-1.29; I²=50%; p=0.23) were observed with early AVR compared with CS, although there was a high degree of heterogeneity between studies.

Conclusions

In this pooled meta-analysis of 4 RCTs, early AVR was associated with a significant reduction in unplanned cardiovascular or HF hospitalization and stroke, and no differences in all-cause and cardiovascular mortality compared with CS.