Aortic valve replacement in asymptomatic severe aortic stenosis. A focused review

Asymptomatic severe aortic stenosis (AS) has traditionally been managed with watchful waiting because of low annual sudden death rates (<1%) and concerns regarding procedural risk. Emerging randomized data indicate that irreversible myocardial injury may occur before symptom onset and that early aortic valve replacement (AVR) may improve outcomes. This review summarizes evidence from contemporary randomized controlled trials evaluating early surgical AVR (SAVR) or transcatheter AVR (TAVR) vs conservative management or surveillance in asymptomatic patients with severe AS and preserved left ventricular ejection fraction (LVEF). The RECOVERY trial randomized 145 asymptomatic patients with very severe AS (mean age 64 years) to early SAVR or conservative care. Over a median follow-up of 6.2 years, all-cause mortality occurred in 1% of the early surgery group vs 15% with conservative management (hazard ratio [HR] 0.09; 95% CI 0.01-0.67; p=0.003). The AVATAR trial included 157 asymptomatic patients with severe AS, preserved LVEF, and negative exercise testing (mean age approximately 67 years). Over a median follow-up of 32 months, the composite endpoint of all-cause death, myocardial infarction, stroke, or heart failure hospitalization occurred in 16.6% of patients assigned to early surgery compared with 32.9% in the conservative group (HR 0.46; 95% CI 0.23-0.90; p=0.02). The EARLY TAVR trial randomized 901 asymptomatic patients with severe AS and preserved LVEF to TAVR or clinical surveillance (mean age 75.8 years). After a median follow-up of 3.8 years, the primary composite outcome of death, stroke, or unplanned cardiovascular hospitalization occurred in 26.8% of the TAVR group versus 45.3% of the surveillance group (HR 0.50; 95% CI 0.40-0.63; p<0.001). Cardiovascular hospitalizations occurred in 20.9% vs 41.7%, all-cause mortality in 8.4% vs 9.2%, and stroke in 4.2% vs 6.7%, with no excess procedural complications in the early TAVR group. Randomized evidence demonstrates that early AVR, including both SAVR and TAVR, reduces mortality and major cardiovascular events in carefully selected asymptomatic patients with severe AS. The integration of clinical features with risk stratification tools, such as global longitudinal strain, cardiac magnetic resonance imaging, natriuretic peptides, and computed tomography-based valve calcification, supports timely intervention before irreversible myocardial damage occurs.