SAVR associated with several long-term benefits for patients with asymptomatic severe AS
Using surgical aortic valve replacement (SAVR) to treat patients with asymptomatic severe aortic stenosis (AS) is associated with better long-term outcomes than a more conservative approach, according to new findings published in European Heart Journal.[1]
“SAVR and, more recently, transcatheter aortic valve replacement (TAVR) procedures are Class I recommendations to relieve symptoms and improve survival in symptomatic patients with severe AS,” wrote first author Marko Banovic, MD, PhD, a cardiologist with Belgrade Medical School and University Clinical Center of Serbia, and colleagues. “Conversely, the question of when and how to treat truly asymptomatic patients with severe AS and normal left ventricular (LV) systolic function is still subject to debate and ongoing research.”
For the AVATAR clinical trial, Banovic and colleagues tracked data from 157 low-risk patients randomized to either undergo early SAVR or conservative treatment. The average age was 67 years old, 57% were men and the median estimated operative mortality risk according to the Society of Thoracic Surgeons score was 1.7%.
The group’s original findings, based on a medium follow-up period of 32 months, were published in Circulation in 2021. Overall, SAVR was linked to a significantly lower rate of the study’s primary endpoint—all-cause death, acute myocardial infarction, stroke or unplanned hospitalization for heart failure—compared to conservative treatment. At the time, the authors said these data provided “preliminary support for early SAVR once AS has become severe, regardless of symptoms.”
An updated perspective on aortic valve replacement in asymptomatic heart patients
This latest analysis represents a long-term update to the AVATAR trial. The median follow-up period was 63 months. The primary endpoint was seen in 23.1% of patients in the early SAVR group and 46.8% of patients in the conservative care group. All-cause mortality, meanwhile, was seen in 16.7% of patients in the early SAVR group and 34.2% of patients in the conservative care group.
The early SAVR group was also linked to a significantly lower risk of a major adverse cardiovascular event.
Banovic et al. also explained that sudden cardiac death was much higher for patients treated with a more conservative treatment strategy.
“It should be noted that several patients experienced sudden cardiac death during the COVID-19 pandemic, at times of suboptimal healthcare accessibility including delays in providing emergency services,” the authors wrote. “Nevertheless, these findings highlight the risk of delays in reporting the symptom onset during the watchful waiting. In this regard, the rigorous watchful waiting with implementation of either regular stress testing or in-person visits with detailed phenotypic screening may mitigate the overall prognostic risk by prompting the timely intervention.”
Reviewing their own data in addition to other studies on this topic, the researchers concluded that all signs “uniformly point at the benefit of early aortic valve intervention.” Additional information is still required, however, including comparisons of SAVR and TAVR among asymptomatic AS patients.
“Given the expansive clinical use of transcatheter approaches, it will be important to elucidate the lifetime strategy and the most-optimal treatment option in these patients in case early transcatheter treatment would favorably impact the clinical outcomes in the trial setting,” the group wrote.
Click here to read the full study in European Heart Journal, a European Society of Cardiology publication.
Michael has more than 16 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.