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
Rizwan Suliankatchi Abdulkader,
Harsimran Singh,
Ashok Seth,
Ravindran Rajendran,
Nagendra Boopathy Senguttuvan,
Nishok Victory Srinivasan,
Manokar Panchanatham,
Asuwin Anandaram,
Dinesh Reddy Polareddy,
Sankaran Ramesh,
Hanumath Yallanki,
Dhamodaran Kaliyamoorthi,
Sundar Chidambaram,
Vadivelu Ramalingam,
Thoddi Ramamurthy Muralidharan,
Ravindar Rao,
Bimmer Claessen,
Parasuram Krishnamoorthy
Affiliations
Rizwan Suliankatchi Abdulkader
Department of Statistics, National Institute of Epidemiology, Chennai, Tamil Nadu, India
Harsimran Singh
Department of Cardiology, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
Ashok Seth
Department of Cardiology, Fortis Escorts Heart Institute and Research Centre, New Delhi, Delhi, India
Ravindran Rajendran
Department of Cardiology, Apollo Hospitals, Trichy, Tamil Nadu, India
Nagendra Boopathy Senguttuvan
Department of Cardiology, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
Nishok Victory Srinivasan
Department of Clinical Research, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
Manokar Panchanatham
Department of Cardiology, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
Asuwin Anandaram
Department of Clinical Research, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
Dinesh Reddy Polareddy
Department of Cardiology, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
Sankaran Ramesh
Department of Cardiology, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
Hanumath Yallanki
Department of Medicine, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
Dhamodaran Kaliyamoorthi
Cardiology, Apollo Hospitals, Chennai, Tamil Nadu, India
Sundar Chidambaram
Department of Cardiology, Kauvery Hospital, Chennai, India
Vadivelu Ramalingam
Department of Cardiology, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
Thoddi Ramamurthy Muralidharan
Department of Cardiology, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
Ravindar Rao
Department of Cardiology, Rajasthan University of Health Sciences, Jaipur, Rajasthan, India
Bimmer Claessen
Department of Cardiology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
Parasuram Krishnamoorthy
Cardiology, Icahn School of Medicine at Mount Sinai Zena and Michael A Wiener Cardiovascular Institute, New York, New York, USA
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), I2=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), I2=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.
