Door-to-Valve Time and Clinical Outcomes in Acute Decompensated Severe Aortic Stenosis: Systematic Review and Meta-Analysis

Background: Acute decompensated aortic stenosis (ADAS) carries high mortality, but the optimal timing of valve intervention is unknown. Objective: To assess the association between time to valve intervention (transcatheter aortic valve replacement [TAVR] or balloon aortic valvuloplasty [BAV]) and clinical outcomes in ADAS. Methods: Embase, Ovid MEDLINE and CENTRAL were searched to May 15, 2026. Hazard ratios (HRs) for delayed versus earlier intervention were pooled using random-effects models with modified Hartung-Knapp inference. Unadjusted short-term mortality risk ratios (RRs) were pooled using the Mantel-Haenszel method. Results: Eight observational cohort studies (n=6,044) met inclusion criteria: six TAVR (n= 5,986) and two BAV (n=58) studies. Patients were approximately 79 years old, and 63% were male. Early-intervention thresholds ranged from <24-48 hours (BAV) to ?22 days (TAVR) from admission. Delayed intervention was not significantly associated with long-term all-cause mortality (HR 1.52, 95% CI 0.46-5.00; p=0.269; I2=58.2%) or mortality per five-day delay (HR 1.09, 95% CI 0.34-3.43; p=0.530; I2=86.7%). Crude short-term mortality was higher with delayed intervention (RR 4.96, 95% CI 1.17-20.92; p=0.029; I2=0.0%), although this association was not robust to sensitivity analyses. Most studies were at serious risk of bias, with substantial heterogeneity in clinical severity, intervention timing, and treatment modality. Conclusion: Point estimates favour earlier intervention, but current observational data do not establish a mortality benefit for an optimal door-to-valve interval, and existing study designs are biased against early treatment. Prospective and randomized-controlled trials on optimal valve intervention timing following ADAS are needed.