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Early intervention or watchful waiting for asymptomatic severe aortic valve stenosis: a systematic review and meta-analysis
Journal of Cardiovascular Medicine  (IF2.16),  Pub Date : 2020-11-01, DOI: 10.2459/jcm.0000000000001110
Waqas Ullah, Smitha Narayana Gowda, Muhammad Shayan Khan, Yasar Sattar, Yasser Al-khadra, Muhammad Rashid, Mohamed O. Mohamed, Mohamad Alkhouli, Samir Kapadia, Rodrigo Bagur, Mamas A. Mamas, David L. Fischman, M. Chadi Alraies

Background 

The management of patients with severe but asymptomatic aortic stenosis is challenging. Evidence on early aortic valve replacement (AVR) versus symptom-driven intervention in these patients is unknown.

Methods 

Electronic databases were searched, articles comparing early-AVR with conservative management for severe aortic stenosis were identified. Pooled adjusted odds ratio (OR) was computed using a random-effect model to determine all-cause and cardiovascular mortality.

Results 

A total of eight studies consisting of 2201 patients were identified. Early-AVR was associated with lower all-cause mortality [OR 0.24, 95% confidence interval (CI) 0.13–0.45, P ≤ 0.00001] and cardiovascular mortality (OR 0.21, 95% CI 0.06–0.70, P = 0.01) compared with conservative management. The number needed to treat to prevent 1 all-cause and cardiovascular mortality was 4 and 9, respectively. The odds of all-cause mortality in a selected patient population undergoing surgical AVR (SAVR) (OR 0.16, 95% CI 0.09–0.29, P ≤ 0.00001) and SAVR or transcatheter AVR (TAVR) (OR 0.53, 95% CI 0.35–0.81, P = 0.003) were significantly lower compared with patients who are managed conservatively. A subgroup sensitivity analysis based on severe aortic stenosis (OR 0.24, 95% CI 0.11–0.52, P = 0.0004) versus very severe aortic stenosis (OR 0.20, 95% CI 0.08–0.51, P = 0.0008) also mirrored the findings of overall results.

Conclusion 

Patients with asymptomatic aortic valve stenosis have lower odds of all-cause and cardiovascular mortality when managed with early-AVR compared with conservative management. However, because of significant heterogeneity in the classification of asymptomatic patients, large scale studies are required.