Early Aortic Valve Intervention in Asymptomatic Severe Aortic Stenosis: A Clinical Dilemma in Evolution

Abstract The management of asymptomatic severe aortic stenosis (AS) has traditionally relied on watchful waiting until the onset of symptoms or left ventricular dysfunction. However, the FDA's approval of transcatheter aortic valve replacement (TAVR) with the Sapien 3 platform in May 2025, based on the EARLY TAVR trial, has intensified the debate over early intervention. This Viewpoint synthesizes evidence from randomized trials (RECOVERY, AVATAR, EVOLVED, EARLY TAVR) and registries (HAVEC, VALVENOR) to evaluate the role of early aortic valve replacement (AVR). Early intervention is associated with reductions in combined endpoints of cardiovascular hospitalizations, stroke, and mortality in selected patients, with the EARLY TAVR demonstrating a 50% reduction in major cardiovascular events. Nonetheless, evidence remains inconsistent, particularly in low-risk populations, as the EVOLVED trial showed no mortality benefit in patients with myocardial fibrosis, warranting cautious interpretation. A conservative surveillance strategy remains appropriate in some cases, supported by the low annual risk of sudden death (i.e., 0.65% per year) and ongoing concerns over valve durability and procedural risks. Given the heterogeneity of patient and valve phenotypes, a personalized risk assessment, combining clinical evaluation, biomarkers (troponin, BNP), and imaging (echocardiography, CMR), is proposed to identify high-risk patients and optimize the timing of early intervention. Expert heart team guidance is essential, and routine early intervention cannot yet be recommended. Further research is needed to refine strategies and improve outcomes in this evolving clinical landscape.

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Publication Details

Journal
European Heart Journal Open
Published
2025-08-29
DOI
https://doi.org/10.1093/ehjopen/oeaf114
Citations
1
Primary Topic
Cardiac Valve Diseases and Treatments
Type
article
Field-Weighted Citation Impact
1.39
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article

Early Aortic Valve Intervention in Asymptomatic Severe Aortic Stenosis: A Clinical Dilemma in Evolution

Tadafumi Sugimoto, Mani A. Vannan, Philippe Pîbarot, Khalil Fattouch et al.
1 citations
European Heart Journal Open
Cardiac Valve Diseases and Treatments
1.39
article

Early Aortic Valve Intervention in Asymptomatic Severe Aortic Stenosis: A Clinical Dilemma in Evolution

Tadafumi Sugimoto, Mani A. Vannan, Philippe Pîbarot, Khalil Fattouch, Erwan Donal, Geu‐Ru Hong, Patrizio Lancellotti, Raluca Dulgheru, Madalina Garbi, Bernard Cosyns, Marco Moscarelli, Augustin Coisne, G. Habib, Jadranka Separovic Hanzevacki
article en
1 citations

Abstract

Abstract The management of asymptomatic severe aortic stenosis (AS) has traditionally relied on watchful waiting until the onset of symptoms or left ventricular dysfunction. However, the FDA's approval of transcatheter aortic valve replacement (TAVR) with the Sapien 3 platform in May 2025, based on the EARLY TAVR trial, has intensified the debate over early intervention. This Viewpoint synthesizes evidence from randomized trials (RECOVERY, AVATAR, EVOLVED, EARLY TAVR) and registries (HAVEC, VALVENOR) to evaluate the role of early aortic valve replacement (AVR). Early intervention is associated with reductions in combined endpoints of cardiovascular hospitalizations, stroke, and mortality in selected patients, with the EARLY TAVR demonstrating a 50% reduction in major cardiovascular events. Nonetheless, evidence remains inconsistent, particularly in low-risk populations, as the EVOLVED trial showed no mortality benefit in patients with myocardial fibrosis, warranting cautious interpretation. A conservative surveillance strategy remains appropriate in some cases, supported by the low annual risk of sudden death (i.e., 0.65% per year) and ongoing concerns over valve durability and procedural risks. Given the heterogeneity of patient and valve phenotypes, a personalized risk assessment, combining clinical evaluation, biomarkers (troponin, BNP), and imaging (echocardiography, CMR), is proposed to identify high-risk patients and optimize the timing of early intervention. Expert heart team guidance is essential, and routine early intervention cannot yet be recommended. Further research is needed to refine strategies and improve outcomes in this evolving clinical landscape.

European Heart Journal Open
Valve (United States) (US), Vrije Universiteit Brussel (BE), University Hospital Centre Zagreb (HR), Inserm (FR), University of Liège (BE), University of Zagreb (HR), Yonsei University (KR), Aix-Marseille Université (FR), Université de Lille (FR), Royal Papworth Hospital (GB), Severance Hospital (KR), Institut Pasteur de Lille (FR), Centre Hospitalier Universitaire de Lille (FR), Nagoya City University (JP), Méditerranée Infection Foundation (FR), Lung Institute (US), Research Foundation of The City University of New York (US), Cambridge University Health Partners (GB), Universitair Ziekenhuis Brussel (BE), Centre Hospitalier Universitaire de Liège (BE), Maria Eleonora Hospital (IT), Gangnam Severance Hospital (KR), Cardiovascular Research Foundation (US), Centre Hospitalier Universitaire de Rennes (FR), Institut de Recherche pour le Développement (FR), Imperial College London (GB), Université de Rennes (FR)
Openalex Percentile: Top 15%
Cardiac Valve Diseases and Treatments
1.39
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