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The following is a summary of “Early Aortic-Valve Replacement in Patients with Asymptomatic Severe Aortic Stenosis with Preserved Left Ventricular Systolic Function: A Systematic Review and Meta-Analysis,” published in the March 2025 issue of American Journal of Cardiology by Pontes et al. 

The optimal management strategy for patients with asymptomatic severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF) remains a subject of ongoing clinical debate. While current guidelines advocate routine clinical surveillance until symptoms or deterioration in cardiac function, the potential benefits of early aortic valve replacement (AVR) before symptom manifestation are not established. To address this uncertainty, researchers conducted a comprehensive systematic review and meta-analysis to compare clinical outcomes between early AVR and conservative management in this patient population. Databases including PubMed, Embase, and Cochrane Library were systematically searched to identify relevant studies involving asymptomatic individuals with severe AS. They preserved LVEF in patients who underwent either early AVR or continued medical observation. 

Statistical analyses were carried out using R software (version 4.3.1) with a random-effects model to account for inter-study variability. Seven eligible studies encompassing a total of 2,531 patients were included, of whom 1,234 (49%) underwent early AVR. The median follow-up duration across studies was 49.3 months. In the pooled analysis, early AVR was significantly associated with reduced all-cause mortality ([HR] 0.51; 95% [CI] 0.31–0.83) and cardiac-specific mortality (RR 0.51; 95% CI 0.30–0.89), indicating a robust survival advantage for those undergoing valve intervention prior to symptom onset. However, when evaluating secondary outcomes—including sudden cardiac death, hospitalization due to cardiovascular causes, stroke, and myocardial infarction- no significant differences were observed between the early AVR and conservatively managed groups in the overall analysis. 

Notably, a subanalysis focusing solely on randomized controlled trials (RCTs) revealed that early AVR was linked to a lower risk of hospitalization for cardiovascular causes (RR 0.41; 95% CI 0.27–0.63) and stroke (RR 0.62; 95% CI 0.40–0.95), while demonstrating no significant difference in all-cause mortality, cardiac death, MI, or sudden death compared to conservative care. These findings suggest that early surgical intervention may confer a mortality benefit and reduce select adverse clinical events, although the consistency of this effect appears to vary based on study design and outcome measures. 

Overall, this meta-analysis highlights the potential value of early AVR in improving survival among patients with asymptomatic severe AS and preserved LVEF, while underscoring the need for individualized risk-benefit assessment and further validation in large-scale prospective trials. The observed discrepancies between overall and RCT-specific outcomes also emphasize the importance of study design in interpreting clinical evidence and shaping treatment recommendations for this nuanced patient group.

Source: ajconline.org/article/S0002-9149(25)00215-2/abstract