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Senguttuvan NB, Srinivasan NV, Panchanatham M, Abdulkader RS, Anandaram A, Polareddy DR, Ramesh S, Singh H, Yallanki H, Kaliyamoorthi D, Chidambaram S, Ramalingam V, Rajendran R, Muralidharan TR, Rao R, Seth A, Claessen B, Krishnamoorthy P. 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. Open Heart 2024; 11:e002511. [PMID: 38191233 PMCID: PMC10806528 DOI: 10.1136/openhrt-2023-002511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/14/2023] [Indexed: 01/10/2024] Open
Abstract
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.
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Affiliation(s)
| | | | - 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
| | | | - Sankaran Ramesh
- Department of Cardiology, SRIHER (Deemed to be University), Chennai, Tamil Nadu, India
| | - Harsimran Singh
- 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
| | | | | | - Vadivelu Ramalingam
- Department of Cardiology, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
| | | | | | - Ravindar Rao
- Department of Cardiology, Rajasthan University of Health Sciences, Jaipur, Rajasthan, India
| | - Ashok Seth
- Department of Cardiology, Fortis Escorts Heart Institute and Research Centre, New Delhi, Delhi, 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
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