Surgical vs Transcatheter Aortic Valve Replacement for Asymptomatic Severe Aortic Stenosis- an Updated Meta-Analysis of Reconstructed Individual Patient Data

Abstract

OBJECTIVES: The management of asymptomatic aortic stenosis (AS) is controversial. We perform a meta-analysis of reconstructed individual patient data to compare conservative treatment versus transcatheter or surgical aortic valve replacement (TAVR or SAVR) in asymptomatic AS. METHODS: PubMed/MEDLINE, Web of Science, Scopus, and Cochrane CENTRAL were systematically searched, through 25th September 2025, to identify any observational or randomized controlled studies that comply with our inclusion criteria. Our primary outcomes were short cardiovascular and non-cardiovascular mortality as well as long-term mortality. We combined aggregate data meta-analysis for dichotomous outcomes using incidence rate ratio (IRR) with reconstructed time-to-event data derived from published Kaplan-Meier curves using validated algorithms. RESULTS: Seventeen studies were included. Overall, AVR was associated with a significantly lower risk of all-cause mortality compared with conservative management (IRR = 0.43; 95% CI, 0.32-0.57; P < .001). Cardiovascular mortality was also significantly reduced with AVR (IRR = 0.47; 95% CI, 0.29-0.75; P < .01; I2 = 62%). The risk of heart failure hospitalization was markedly lower among AVR recipients (IRR = 0.39; 95% CI, 0.22-0.67; P < .01), with consistent benefit across study designs. AVR was further associated with a substantial reduction in sudden cardiac death (IRR = 0.13; 95% CI, 0.04-0.48; P < .01) and myocardial infarction (IRR = 0.11; 95% CI, 0.04-0.31; P = .03). The risk of stroke was not significantly different between groups (IRR = 0.77; 95% CI, 0.58-1.02; P = .07). Reconstructed Kaplan-Meier analyses demonstrated durable long-term survival benefit with AVR, consistent across surgical and transcatheter approaches. CONCLUSIONS: Patients with asymptomatic AS, managed with either SAVR or TAVR, were associated with lower short- and long-term mortality compared to conservative management.