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Aortic Valve Replacement vs Conservative Treatment in Patients With Asymptomatic Severe Aortic Stenosis: Long-Term Outcomes
TAKE-HOME MESSAGE
- In this long-term extension of the AVATAR trial, early aortic valve replacement in patients with asymptomatic severe aortic stenosis was associated with a 58% lower risk of the primary composite endpoint of all-cause death, acute myocardial infarction, stroke, and hospitalization for heart failure than usual care at 5 years.
- These findings suggest that earlier interventions in patients with severe aortic stenosis, similar to the established approach to managing modifiable and progressive risk factors, may improve clinical outcomes. Larger prospective trials are needed to confirm these findings.
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND AND AIMS
The question of when and how to treat truly asymptomatic patients with severe aortic stenosis (AS) and normal left ventricular (LV) systolic function is still subject to debate and ongoing research. Here, the results of extended follow-up of the AVATAR trial are reported (NCT02436655, clinical trials.gov).
METHODS
The AVATAR trial randomly assigned patients with severe, asymptomatic AS and LV ejection fraction ≥50% to undergo either early surgical aortic valve replacement (AVR) or conservative treatment with watchful waiting strategy. All patients had negative exercise stress testing. The primary hypothesis was that early AVR will reduce a primary composite endpoint comprising all-cause death, acute myocardial infarction, stroke or unplanned hospitalization for heart failure (HF), as compared to conservative treatment strategy.
RESULTS
A total of 157 low-risk patients (mean age 67 years, 57% men, mean Society of Thoracic Surgeons score 1.7%) were randomly allocated to either early AVR group (n=78) or conservative treatment group (n=79). In an intention-to-treat analysis, after a median follow-up of 63 months, the primary composite endpoint outcome event occurred in 18/78 patients (23.1%) in the early surgery group and in 37/79 patients (46.8%) in the conservative treatment group (hazard ratio [HR] early surgery vs. conservative treatment 0.42; 95% confidence interval [CI] 0.24-0.73, p=0.002). The Kaplan-Meier estimates for individual endpoints of all-cause death and HF hospitalization were significantly lower in the early surgery compared with the conservative group (HR 0.44; 95% CI 0.23-0.85, p=0.012 for all-cause death, and HR 0.21; 95% CI 0.06-0.73, p=0.007 for HF hospitalizations).
CONCLUSIONS
The extended follow-up of the AVATAR trial demonstrates better clinical outcomes with early surgical AVR in truly asymptomatic patients with severe AS and normal LV ejection fraction compared with patients treated with conservative management on watchful waiting.
Additional Info
Aortic valve replacement versus conservative treatment in asymptomatic severe aortic stenosis: long-term follow-up of the AVATAR trial
Eur Heart J 2024 Sep 01;[EPub Ahead of Print], M Banovic, S Putnik, BR Da Costa, M Penicka, MA Deja, M Kotrc, R Kockova, S Glaveckaite, H Gasparovic, N Pavlovic, L Velicki, S Salizzoni, W Wojakowski, G Van Camp, S Gradinac, M Laufer, S Tomovic, I Busic, M Bojanic, A Ristic, A Klasnja, M Matkovic, N Boskovic, K Zivic, M Jovanovic, SD Nikolic, B Iung, J BartunekFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.