Early Surgery or Conservative Care for Asymptomatic Aortic Stenosis at 10 Years.

Summary

In asymptomatic patients with very severe aortic stenosis (n=145), early surgery reduced the 10-year cumulative incidence of operative mortality or cardiovascular death to 1% vs 19% with conservative care (HR 0.10). All-cause mortality was also lower with early surgery (15% vs 32%; HR 0.42), supporting proactive intervention.

Key Findings

• Primary endpoint (operative mortality or cardiovascular death) at 10 years: 1% early surgery vs 19% conservative care (HR 0.10; 95% CI 0.02–0.43; P=0.002).
• All-cause mortality: 15% early surgery vs 32% conservative care (HR 0.42; 95% CI 0.21–0.86).
• Benefits observed in intention-to-treat analysis, reinforcing robustness despite modest sample size.

Clinical Implications

Supports considering early surgical aortic valve replacement in asymptomatic very severe stenosis to reduce long-term cardiovascular and all-cause mortality, with shared decision-making and surgical risk assessment.

Limitations

• Modest sample size (n=145) and conducted in a specific healthcare setting, which may limit generalizability.
• Evolving surgical and transcatheter techniques over a decade could influence applicability.

Future Directions

Comparative trials and registries integrating contemporary SAVR vs TAVR in asymptomatic very severe AS, with quality-of-life and cost-effectiveness endpoints.