• Yujiro Yokoyama, Hisato Takagi, and Toshiki Kuno.
• Department of Surgery, St. Luke's University Health Network, Bethlehem, Pa.
• J. Thorac. Cardiovasc. Surg. 2022 May 1; 163 (5): 1778-1785.e5.

ObjectiveAlthough current guidelines generally recommend watchful waiting strategy for patients with asymptomatic severe aortic stenosis until symptoms develop, early surgery for asymptomatic aortic stenosis remains controversial. This study aimed to compare the outcomes of early surgery versus conservative strategy for patients with asymptomatic severe aortic stenosis.MethodsMEDLINE and EMBASE were searched through February 2020 to identify clinical trials that investigated early surgery and conservative strategy for patients with asymptomatic severe aortic stenosis. From each study, we extracted the hazard ratio of all-cause mortality and cardiovascular mortality. Subgroup analyses were conducted by dividing into severe aortic stenosis (peak aortic jet velocity ≥4.0 m/s, mean aortic pressure gradient ≥40 mm Hg, or aortic valve area ≤1.0 cm2) and very severe aortic stenosis (peak aortic jet velocity ≥4.5 m/s, mean pressure gradient ≥50 mm Hg, or aortic valve area ≤0.75 cm2) groups.ResultsOne randomized controlled trial and 7 observational studies were identified. Pooled analyses demonstrated that all-cause mortality and cardiovascular mortality for early surgery were significantly lower compared with conservative strategy (hazard ratio, 0.49; 95% confidence interval, 0.36-0.68; P < .0001, hazard ratio, 0.42; 95% confidence interval, 0.22-0.82; P = .01, respectively). Subgroup analyses showed significant reduction for early surgery in all-cause mortality (severe aortic stenosis: hazard ratio, 0.52; 95% confidence interval, 0.35-0.78; P = .001, very severe aortic stenosis: hazard ratio, 0.38; 95% confidence interval, 0.17-0.85; P = .02).ConclusionsWe demonstrated that early surgery was associated with significant reduction in all-cause and cardiovascular mortality in patients with severe aortic stenosis. Further randomized trials are warranted to confirm our findings.Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

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