Timing of surgery for asymptomatic patients with severe aortic valve stenosis: An updated systematic review and meta-analysis

Background: The research findings concerning the effect of early surgery on mortality among asymptomatic patients with severe aortic valve stenosis (AS) are controversial and contradictory. In this study, the total weight of evidence regarding early surgery versus conservative management in these population was examined. Methods: Embase, PubMed, CENTRAL, and CINAHL databases were thoroughly searched without language restriction until 29 February, 2020. We included all studies exploring the mortality in asymptomatic patients with severe AS comparing early surgery with conservative management and obtained data in a standard form. Pooled relative risks ratios (RRs) and 95% confidence intervals (CI) were pooled by using a random- or fixed-effects model and by using intention-to-treat principle. Randomized controlled trials (RCTs) and observational studies (OSs) were analyzed separately. Results: Finally, 8 studies involving 2462 patients were enrolled, including 1 RCT and 7 OSs. In the OSs, early surgery was linked with significant reduction among all-cause mortality (RR & 95% CI, I2: 0.32 (0.18-0.57), 84.9%) and cardiac death (0.28 (0.18–0.45), 62.5%) in asymptomatic patients with severe AS. The superiority of early surgery over conservative management in reducing all-cause mortality in these patients is also intensified in the RCT. Conclusions: The existing RCT and OSs indicate that earlier surgery is associated with better outcomes for asymptomatic patients with severe AS. Nevertheless, more well-designed and large-sized RCTs are needed to find an individual approach focusing on individual risk stratification and staging