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

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

PubMed, Embase, and ClinicalTrials.gov were searched through November 2024 for randomized controlled trials (RCTs) and observational studies comparing surgical aortic valve replacement or transcatheter aortic valve replacement with CS in patients with asymptomatic severe aortic stenosis.

Sixteen eligible studies (12 observational studies and 4 RCTs) were identified, with a total of 3919 patients in the observational studies and 1427 patients in the RCTs. In the pooled analyses combining observational studies and RCTs, aortic valve replacement (AVR) was associated with significantly reduced all-cause mortality (incidence rate ratio [IRR], 0.42; 95% CI, 0.31-0.58; P < .01; I ² = 72%), cardiovascular mortality (IRR, 0.46; 95% CI, 0.28-0.78; P < .01; I ² = 68%), and unplanned cardiovascular or heart failure (HF)-related hospitalization (IRR, 0.34; 95% CI, 0.21-0.55; P < .01; I ² = 50%). In 12 observational studies, AVR was associated with significantly lower rates of all-cause mortality (IRR, 0.36; 95% CI, 0.27-0.49; P < .01; I ² = 65%), and cardiovascular mortality (IRR, 0.33; 95% CI, 0.16-0.70; P < .01; I ² = 71%) compared with CS. In 4 RCTs, there was no significant difference in all-cause or cardiovascular mortality, but AVR was associated with a significant reduction in unplanned cardiovascular or HF hospitalization (IRR, 0.42; 95% CI, 0.26-0.65; P < .01; I ² = 27%) and stroke (IRR, 0.63; 95% CI, 0.40-0.98; P = .04; I ² = 0%).

Data from observational studies and recent RCTs suggest that a strategy of preemptive AVR is associated with improved survival and lower rates of unplanned cardiovascular or HF-related hospitalizations and stroke compared to CS.