Early Aortic Valve Replacement Versus Clinical Surveillance in Asymptomatic Patients With Severe Aortic Stenosis

The optimal timing for aortic valve replacement (AVR) in asymptomatic patients with severe aortic stenosis (AS) remains debatable. This study aimed to compare the clinical outcomes of early AVR and clinical surveillance in asymptomatic patients with high-gradient severe AS. Among 3369 patients enrolled in the CURRENT AS Registry-2, which included consecutive patients with severe AS, we identified 596 asymptomatic patients with high-gradient severe AS (initial AVR strategy: 285 patients; clinical surveillance strategy: 311 patients). A propensity score-matched cohort was constructed, comprising 206 patients each in the initial AVR and clinical surveillance groups. The primary outcome measure was a composite of all-cause death, stroke, or hospitalization for heart failure (HF). In the propensity score-matched cohort, the mean age was 79.6 years, and the median Society of Thoracic Surgeons-predicted risk of mortality was 3.2%. In the initial AVR group, surgical and transcatheter AVR were performed in 83 and 123 patients, respectively, whereas in the clinical surveillance group, conversion to AVR occurred in 11.1%, 32.9%, and 69.0% patients at 6 months, 1 year, and 3 years. The cumulative 3-year incidence of the primary outcome was not significantly different between the initial AVR and clinical surveillance groups (26.4% vs 28.4%; log-rank p = 0.46; hazard ratio [HR]: 0.85, 95% confidence interval [CI]: 0.56-1.29). In conclusion, in asymptomatic patients with high-gradient severe AS, the initial AVR strategy compared to clinical surveillance was not associated with a lower risk for a composite of all-cause death, stroke or hospitalization for HF.