Cardiologists agree: Early TAVR or SAVR for asymptomatic severe AS limits strokes, hospitalizations
Great minds think alike, as the old saying goes, and that sure seems to be the case among cardiologists.
Two separate research teams have published similar studies comparing early aortic valve replacement (AVR) with clinical surveillance (CS) for the treatment of asymptomatic severe aortic stenosis (AS). Both studies were meta-analyses of the same four randomized controlled trials (RCTs)—and they were even published at roughly the same time.
As one may expect, the two research teams reached the same conclusion: Early AVR, either transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR), was associated with significant improvements in patient outcomes.
A closer look at the two meta-analyses
One meta-analysis was performed by corresponding author Philippe Généreux, MD, an interventional cardiologist with the Gagnon Cardiovascular Institute at Morristown Medical Center in New Jersey, and colleagues. It was published in the Journal of American College of Cardiology (JACC).[1]
The other meta-analysis was performed by corresponding author Somjot S. Brar, MD, an interventional cardiologist with Kaiser Permanente School of Medicine in Pasadena, California, and colleagues. It was published in the American Journal of Cardiology (AJC).[2]
Both groups evaluated data from 1,427 patients with asymptomatic severe AS who participated in one of four RCTs: RECOVERY, AVATAR, EVoLVeD or EARLY TAVR. While 719 patients underwent early AVR for their symptoms, the other 708 patients underwent clinical surveillance as recommended by modern guidelines. The average follow-up period was 4.1 years.
Overall, the two research teams both found that early AVR—either TAVR or SAVR—was associated with a significantly reduced risk of patients requiring an unplanned hospitalization or experiencing a stroke. There was not a statistically significant difference in all-cause mortality.
Researchers reflect on their findings
In AJC, Brar et al. wrote that these findings suggest CS may not always be the best course of action for patients with asymptomatic severe AS.
“A more proactive approach in selected patients may mitigate the risks associated with unplanned hospitalizations and emergency procedures,” they wrote. “Future research should focus on identifying subgroups most likely to benefit from early intervention and on clarifying its long-term impact on survival and functional outcomes. Such evidence could inform guideline updates to optimize the timing of AVR for asymptomatic severe AS.”
Généreux et al. shared a similar perspective in JACC.
“Given the benefits observed and lack of harm, a strategy of prompt AVR may be preferred for patients with asymptomatic severe AS,” they wrote.
Généreux et al. also wrote that the stroke reduction associated with early AVR was “somewhat unexpected.”
“One of the major concerns of performing early AVR is the possibility of procedure-related complications such as stroke, major vascular complications or bleeding,” the group wrote. “The incidence of periprocedural disabling stroke using current generation TAVR platforms is about 1% to 2% in real-world registries. Stroke rates are substantial in patients with untreated AS, and it is possible that replacement of a diseased aortic valve may reduce the risk for valve-related thromboembolic events or the development of subclinical atrial fibrillation (with an associated high risk for thrombo-embolism) due to prolonged exposure to the AS-related pressure overload on the left ventricle and atrium. Further prospective studies are needed to confirm this finding.”
Michael has more than 19 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.