TY - JOUR
T1 - Systematic review and meta-analysis of early aortic valve replacement versus conservative therapy in patients with asymptomatic aortic valve stenosis with preserved left ventricle systolic function
AU - Senguttuvan, Nagendra Boopathy
AU - Srinivasan, Nishok Victory
AU - Panchanatham, Manokar
AU - Abdulkader, Rizwan Suliankatchi
AU - Anandaram, Asuwin
AU - Polareddy, Dinesh Reddy
AU - Ramesh, Sankaran
AU - Singh, Harsimran
AU - Yallanki, Hanumath
AU - Kaliyamoorthi, Dhamodaran
AU - Chidambaram, Sundar
AU - Ramalingam, Vadivelu
AU - Rajendran, Ravindran
AU - Muralidharan, Thoddi Ramamurthy
AU - Rao, Ravindar
AU - Seth, Ashok
AU - Claessen, Bimmer
AU - Krishnamoorthy, Parasuram
N1 - Publisher Copyright: © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
PY - 2024/1/8
Y1 - 2024/1/8
N2 - Background A quarter of patients with severe aortic stenosis (AS) were asymptomatic, and only a third of them survived at the end of 4 years. Only a select subset of these patients was recommended for aortic valve replacement (AVR) by the current American College of Cardiology/American Heart Association guidelines. We intended to study the effect of early AVR (eAVR) in this subset of asymptomatic patients with preserved left ventricle function. Methods and results We searched PubMed and Embase for randomised and observational studies comparing the effect of eAVR versus conservative therapy in patients with severe, asymptomatic AS and normal left ventricular function. The primary outcome was all-cause mortality. The secondary outcomes were composite major adverse cardiac events (MACE) (study defined), myocardial infarction (MI), stroke, cardiac death, sudden death, the development of symptoms, heart failure hospitalisations and major bleeding. We used GRADEPro to assess the certainty of the evidence. In the randomised controlled trial (RCT) only analysis, we found no significant difference in all-cause mortality between the early aortic intervention group versus the conservative arm (CA) (incidence rate ratio, IRR (CI): 0.5 (0.2 to 1.1), I 2 =31%, p=0.09). However, in the overall cohort, we found mortality benefit for eAVR over CA (IRR (CI): 0.4 (0.3 to 0.7), I 2 =84%, p<0.01). There were significantly lower MACE, cardiac death, sudden death, development of symptoms and heart failure hospitalisations in the eAVR group. We noticed no difference in MI, stroke and major bleeding. Conclusion We conclude that there is no reduction in all-cause mortality in the eAVR arm in patients with asymptomatic AS with preserved ejection fraction. However, eAVR reduces heart failure related hospitalisations and death or heart failure hospitalisations. PROSPERO registration number CRD42022306132.
AB - Background A quarter of patients with severe aortic stenosis (AS) were asymptomatic, and only a third of them survived at the end of 4 years. Only a select subset of these patients was recommended for aortic valve replacement (AVR) by the current American College of Cardiology/American Heart Association guidelines. We intended to study the effect of early AVR (eAVR) in this subset of asymptomatic patients with preserved left ventricle function. Methods and results We searched PubMed and Embase for randomised and observational studies comparing the effect of eAVR versus conservative therapy in patients with severe, asymptomatic AS and normal left ventricular function. The primary outcome was all-cause mortality. The secondary outcomes were composite major adverse cardiac events (MACE) (study defined), myocardial infarction (MI), stroke, cardiac death, sudden death, the development of symptoms, heart failure hospitalisations and major bleeding. We used GRADEPro to assess the certainty of the evidence. In the randomised controlled trial (RCT) only analysis, we found no significant difference in all-cause mortality between the early aortic intervention group versus the conservative arm (CA) (incidence rate ratio, IRR (CI): 0.5 (0.2 to 1.1), I 2 =31%, p=0.09). However, in the overall cohort, we found mortality benefit for eAVR over CA (IRR (CI): 0.4 (0.3 to 0.7), I 2 =84%, p<0.01). There were significantly lower MACE, cardiac death, sudden death, development of symptoms and heart failure hospitalisations in the eAVR group. We noticed no difference in MI, stroke and major bleeding. Conclusion We conclude that there is no reduction in all-cause mortality in the eAVR arm in patients with asymptomatic AS with preserved ejection fraction. However, eAVR reduces heart failure related hospitalisations and death or heart failure hospitalisations. PROSPERO registration number CRD42022306132.
KW - Aortic Valve Stenosis
KW - Heart Valve Prosthesis Implantation
KW - Outcome Assessment, Health Care
KW - Transcatheter Aortic Valve Replacement
UR - http://www.scopus.com/inward/record.url?scp=85182380777&partnerID=8YFLogxK
U2 - https://doi.org/10.1136/openhrt-2023-002511
DO - https://doi.org/10.1136/openhrt-2023-002511
M3 - Article
C2 - 38191233
SN - 2398-595X
VL - 11
JO - Open Heart
JF - Open Heart
IS - 1
M1 - e002511
ER -