Early aortic valve replacement for asymptomatic severe aortic stenosis: an updated systematic review and meta-analysis

Background The optimal timing of intervention in asymptomatic severe aortic stenosis remains debated. This updated meta-analysis evaluates the comparative effects of early surgical or transcatheter aortic valve replacement (AVR) versus conservative management by incorporating recent long-term randomized evidence. Methods We performed a systematic review and meta-analysis of randomized trials comparing early AVR with conservative management in asymptomatic severe AS. Hazard ratios and 95% confidence intervals were pooled using a random-effects model, and exploratory meta-regression analyses were conducted to identify potential treatment-effect modifiers. Results Across the included randomized trials, an early intervention strategy was associated with significant reductions in cardiovascular hospitalizations, heart failure hospitalizations, and stroke. Reductions in all-cause and cardiovascular mortality favored early intervention but did not achieve statistical significance. Treatment benefits varied according to clinical and hemodynamic profiles: greater baseline valve severity was associated with larger therapeutic effects, whereas increasing comorbidity burden (such as diabetes) tended to result in inferior clinical outcomes. Conclusions In asymptomatic severe AS, an early AVR strategy consistently reduces cardiovascular and heart failure hospitalizations and stroke compared with conservative surveillance, despite neutral effects on overall and cardiovascular mortality. These findings support a contemporary shift toward an individualized, phenotype-driven approach rather than universal early intervention. Integrating hemodynamic severity and comorbidity burden can help identify patients most likely to derive net clinical benefit from early valve replacement.