Asymptomatic severe aortic stenosis, conservative treatment or early valve replacement? a systematic review and meta-analysis

Abstract

Abstract Funding Acknowledgements Type of funding sources: None. Background Asymptomatic aortic stenosis’ management is not only a daily practice challenge but also an area of clinical research controversy. As evidence on conservative versus early aortic valve replacement (AVR) is debatable, we conducted a systematic review and meta-analysis to compare the efficacy of conservative management versus AVR in asymptomatic aortic stenosis (AS). Methods Electronic databases were systematically searched to identify any observational or interventional studies that compared the effects of conservative management versus AVR on all causes, cardiovascular, non-cardiovascular mortality. Pooled risk ratios (RR) and their 95% confidence intervals (CI) were calculated using random-effects models. Results A total of 6216 patients were included from 12 studies (observational=9, and randomized clinical trial=3) with a mean follow-up duration of 50 months. When compared to early AVR, conservative management has statistically significant higher risk of all causes mortality (RR: 0.36, 95%CI [0.31 to 0.42], p<0.00001, figure 1), cardiovascular mortality (RR: 0.32, 95%CI [0.24 to 0.41], p<0.00001, figure 2), and non-cardiovascular mortality (RR: 0.42, 95%CI [0.24 to 0.56], p=0.0005). Regarding other complications, conservative treatment showed significant higher risk of sudden cardiac death (RR: 0.46, 95%CI [0.15 to 0.90], p=0.005), yet with no difference over AVR in stroke and myocardial infarction (RR: 0.79, 95% CI [0.17 to 3.64], p=0.61) and (RR: 0.67, 95% CI [0.39 to 1.16], p=0.15), respectively. A subgroup sensitivity analysis based on surgical AVR vs. transcatheter AVR and severe vs. very severe AS reflected the findings of the overall results. Conclusions Patients with asymptomatic aortic valve stenosis, managed with early AVR, have a lower risk of all-cause, cardiovascular, and non-cardiovascular mortality when compared to conservative management.