Surgical Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis: An Updated Systematic Review and Meta-Analysis

• Published in: Cardiovascular revascularization medicine Vol. 42; pp. 36 - 44
• Main Authors: Ismayl, Mahmoud, Machanahalli Balakrishna, Akshay, Abusnina, Waiel, Thandra, Abhishek, Walters, Ryan W., Alugubelli, Navya R., Yackley, Steven, Betts, Lucas, Smer, Aiman, Goldsweig, Andrew M., Dahal, Khagendra
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-09-2022
• Subjects: Asymptomatic aortic stenosis; Conservative treatment; Severe aortic stenosis; Surgical aortic valve replacement; RCT; Surgical aortic valve replacement; Vmax; LVEF; HFH; SAVR; AVA; TAVR; AS; MAG; Asymptomatic aortic stenosis; SCD; Severe aortic stenosis; MI; AVR; Conservative treatment
• ISSN: 1553-8389; 1878-0938
• DOI: 10.1016/j.carrev.2022.03.001

While aortic valve replacement (AVR) is indicated for symptomatic severe aortic stenosis (AS), the appropriate management of asymptomatic severe AS remains unclear. We conducted an updated meta-analysis to compare the outcomes of surgical AVR (SAVR) versus conservative treatment in patients with asymptomatic severe AS.
We searched PubMed, EMBASE, Cochrane, clinicaltrials.gov, and Google Scholar for studies comparing outcomes of SAVR versus conservative treatment in asymptomatic severe AS. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated for each individual study. Outcomes included all-cause mortality, cardiovascular and non-cardiovascular mortality, 30-day operative mortality, sudden cardiac death (SCD), heart failure hospitalization (HFH), myocardial infarction (MI), and stroke.
A total of 8 studies with 2685 patients were included. The mean age was above 60 years, and the median follow-up duration was 4 years. Compared to conservative treatment, SAVR was associated with significantly lower all-cause mortality (RR 0.39; 95% CI 0.23–0.64) and HFH rates (RR 0.18; 95% CI 0.05–0.71). There were no significant differences in cardiovascular mortality (RR 0.24; 95% CI 0.03–1.67), non-cardiovascular mortality (RR 0.49; 95% CI 0.23–1.03), 30-day operative mortality (RR 0.48; 95% CI 0.10–2.32), SCD (RR 0.37; 95% CI 0.05–2.89), MI (RR 0.48; 95% CI 0.04–5.52), and stroke rates (RR 1.20; 95% CI 0.35–4.11) between the two strategies.
In patients with asymptomatic severe AS, SAVR is associated with significantly lower all-cause mortality and HFH compared to conservative treatment. While SAVR is a promising option for asymptomatic severe AS, most studies were observational and nonrandomized; randomized trials are needed to establish a clear benefit.
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•While valve replacement is indicated for symptomatic severe AS, the correct management of asymptomatic patients is unclear.•SAVR is associated with lower mortality and HF hospitalizations compared to conservative treatment in asympatomic severe AS.•Given the mortality benefit, SAVR may be indicated in patients with asymptomatic severe AS.