Early aortic valve intervention versus clinical surveillance in patients with asymptomatic severe aortic stenosis: a systematic review and meta-analysis

Background The optimal timing of aortic valve replacement (AVR) in patients with asymptomatic severe aortic stenosis (AS) remains uncertain. The aim of this study was to evaluate the efficacy and safety of early AVR compared to clinical surveillance (CSV) in patients with asymptomatic severe AS. Methods We systematically searched PubMed, Embase, Cochrane Library, Web of Science, and Scopus through August 2025 for studies that compared early AVR with conservative management in asymptomatic patients with severe AS. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models. Results Eight studies including four randomized controlled trials and four propensity-matched observational studies, enrolling 3,086 patients, of whom 1,539 (49.9%) underwent early AVR were included. Compared with CSV, AVR was associated with significant reduction in MACE (OR: 0.41, 95% CI: 0.29–0.59; P < 0.001), all-cause mortality (OR: 0.59, 95% CI: 0.39–0.88; P = 0.011), cardiovascular mortality (OR: 0.49, 95% CI: 0.35–0.69; P < 0.001), hospitalization for heart failure (OR 0.36, 95% CI 0.20–0.65; P < 0.001), and sudden death (OR: 0.51, 95% CI: 0.29–0.88; P = 0.015). Major vascular bleeding was more frequent in the early AVR group than in the conservative surveillance group (OR: 1.75, 95% CI: 1.05–2.92; P = 0.032). The risk of myocardial infarction, stroke, pacemaker implantation, or infective endocarditis were similar between groups. Conclusion In patients with asymptomatic severe aortic stenosis, an early AVR strategy was associated with reduced heart failure hospitalization, favorable composite and procedural safety outcomes compared with CSV. Although a survival benefit was observed in pooled analyses, this was not consistently demonstrated in randomized trials. These findings support a more individualized approach to the timing of intervention. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/view/ CRD420251135500.