Early aortic valve replacement linked with improved outcomes versus conservative management

1. Patients with asymptomatic severe aortic stenosis receiving early valve replacement had a lower incidence of operative mortality or death due to cardiovascular causes compared to patients receiving conservative care

Evidence Level: 1 (Excellent)

Aortic stenosis is the most common valvular disease with surgical indications in developed countries, with aortic-valve replacement being the only effective treatment option for severe symptomatic stenosis. Currently, the consensus opinion is to reserve surgical intervention for patients with symptomatic severe aortic stenosis, with observation and conservative management for asymptomatic patients. In asymptomatic patients, surgical risks have been largely regarded as outweighing the potential benefits of valve replacement. Advancements in surgical techniques, technology, and postoperative care, however, have raised questions surrounding the safety of performing valve replacement earlier in asymptomatic patients. In this multicenter, randomized controlled trial, 145 asymptomatic patients with very severe aortic stenosis (aortic-valve area of ≤0.75 cm² with either an aortic jet velocity of ≥4.5 m per second or a mean transaortic gradient of ≥50 mm Hg) between July 2010 through April 2015 to either undergo early surgery group or receive conservative care. The primary end point was a composite of operative mortality, consisting of death during or within 30 days of surgery, or death from cardiovascular causes during the entire follow up period (median follow up 6.2 years). Researchers found there was no operative mortality found in the early intervention group, and, in an intention-to-treat analysis, the early treatment group had significantly fewer end events compared to the conservative treatment group (HR 0.09, 95% CI 0.01 to 0.67, p=0.003). The incidence of death due to any cause was also lower in the intervention group compared to the conservative treatment group. This study therefore supports earlier surgical intervention for asymptomatic patients with very severe aortic stenosis, with reduced operative risk possibly owing to improved surgical technique and postoperative care.

Click to read the study in NEJM

Image: PD

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