Surgical aortic valve replacement versus conservative treatment in asymptomatic severe aortic stenosis: An updated systematic review and meta-analysis

Background: While aortic valve replacement (AVR) is indicated for symptomatic severe aortic stenosis (AS), the appropriate management of asymptomatic severe AS remains unclear. We conducted an updated meta-analysis to compare the outcomes of surgical AVR (SAVR) versus conservative treatment in patients with asymptomatic severe AS. Methods: We searched PubMed, EMBASE, Cochrane, clinicaltrials.gov, and Google Scholar for studies comparing outcomes of SAVR versus conservative treatment in asymptomatic severe AS. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated for each individual study. Outcomes included all-cause mortality, cardiovascular and non-cardiovascular mortality, 30-day operative mortality, sudden cardiac death (SCD), heart failure hospitalization (HFH), myocardial infarction (MI), and stroke. Results: A total of 8 studies with 2685 patients were included. The mean age was above 60 years, and the median follow-up duration was 4 years. Compared to conservative treatment, SAVR was associated with significantly lower all-cause mortality (RR 0.39; 95% CI 0.23–0.64) and HFH rates (RR 0.18; 95% CI 0.05–0.71). There were no significant differences in cardiovascular mortality (RR 0.24; 95% CI 0.03–1.67), non-cardiovascular mortality (RR 0.49; 95% CI 0.23–1.03), 30-day operative mortality (RR 0.48; 95% CI 0.10–2.32), SCD (RR 0.37; 95% CI 0.05–2.89), MI (RR 0.48; 95% CI 0.04–5.52), and stroke rates (RR 1.20; 95% CI 0.35–4.11) between the two strategies. Conclusions: In patients with asymptomatic severe AS, SAVR is associated with significantly lower all-cause mortality and HFH compared to conservative treatment. While SAVR is a promising option for asymptomatic severe AS, most studies were observational and nonrandomized; randomized trials are needed to establish a clear benefit.