Cardiologists recommend AVR for asymptomatic severe AS—TAVR and surgery both viable options

Three leading voices in cardiology have proposed that aortic valve replacement (AVR) should be the default treatment option for patients with asymptomatic severe aortic stenosis (AS) instead of clinical surveillance (CS). There would be room for exceptions due to anatomy or other clinical factors, the group added, but years of research have demonstrated that prompt AVR results in the best possible outcome for a majority of patients.

The authors shared their assessment in JAMA Cardiology, noting that TAVR and SAVR can both result in positive outcomes for patients who present with asymptomatic severe AS. They believe the choice between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) is one that should be made on a case-by-case basis. 

“As with symptomatic patients, no specification is warranted regarding the AVR approach; the choice of TAVR vs SAVR should be made based on anatomical suitability, age, comorbidities and patient preference,” wrote first author Brian R. Lindman, MD, MSc, an associate professor and medical director of the Structural Heart and Valve Center at Vanderbilt University Medical Center, and colleagues. “We also propose that in the absence of a comorbidity that would otherwise limit life expectancy to less than one year, prompt referral to the multidisciplinary heart valve team should be recommended when severe AS may be present.”

AVR for asymptomatic severe AS: Exploring the evidence

Lindman et al. reviewed multiple randomized clinical trials (RCT) to help guide their decision. 

EARLY TAVR, for instance, included data from 901 patients 65 years old or older with asymptomatic, severe AS.[2] Patients were randomized to either undergo transfemoral TAVR with a balloon-expandable Edwards Lifesciences device or CS. The mean patient age was 75.8 years old, 69% were men and the mean Society of Thoracic Surgeons risk score was 1.8%. Overall, the study’s primary endpoint—a composite of all-cause mortality, stroke or unplanned cardiovascular hospitalizations—was seen in 26.8% of TAVR patients and 45.3% of clinical surveillance patients. EARLY TAVR made waves throughout the cardiology community back in October 2024 when it was presented as a late-breaking clinical trial at TCT 2024 in Washington, D.C. 

AVATAR, meanwhile, included data from 157 low-risk patients randomized to either undergo SAVR or conservative treatment.[3] The average age was 67 years, 57% were men and the median estimated operative mortality risk according to the Society of Thoracic Surgeons score was 1.7%. According to a 2024 update of AVATAR that included a median follow-up period of 63 months, the study’s primary endpoint—all-cause death, acute myocardial infarction, stroke or unplanned hospitalization for heart failure—was seen in 23.1% of patients in the early SAVR group and 46.8% in the conservative treatment group.

“While uncertainty about valve durability remains despite encouraging data to date, this should not be a deterrent to an early intervention strategy for asymptomatic patients with severe AS when one considers that crossover timing will be difficult to predict, and the valve durability clocks will start within one to two years of each other regardless of whether an early AVR or CS strategy is chosen; accordingly, the likelihood of a repeat procedure will be similar,” the authors wrote.