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There is no question that aortic valve replacement (AVR) improves survival and reduces symptoms in symptomatic adults with severe aortic stenosis (AS); this recommendation in both European Society of Cardiology and American Heart Association/American College of Cardiology guidelines is supported by high-quality clinical trials, observational data and clinical experience. However, it remains controversial whether AVR would improve long-term outcomes in adults with severe AS who have not yet developed symptoms. Given the absence of a randomised clinical trial to address this question, Lim et al (see page 268) performed a meta-analysis of four observational studies (with a total of 1300 patients) that compared AVR at symptom onset to AVR in the absence of symptoms in adults with severe AS. The pooled data showed no significant difference between an early AVR versus symptom-driven AVR approach in cardiac mortality (OR 0.78, p=0.85) or sudden death (OR 0.34, p=0.25). There was a trend toward reduced overall mortality with early AVR using a random effects model, which is the most appropriate statistical approach given heterogeneity between studies (figure 1). The authors conclude, “We do not believe the data are sufficient to change clinical practice until more robust, randomised data are available.”
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