Généreux Philippe, Banovic Marko, Kang Duk-Hyun, Giustino Gennaro, Prendergast Bernard D, Lindman Brian R, Newby David E, Pibarot Philippe, Redfors Björn, Schwartz Allan, Seyedin Roxanna, Iung Bernard, Dweck Marc R
Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey.
Belgrade Medical School, University of Belgrade, Serbia.
J Soc Cardiovasc Angiogr Interv. 2025 May 2;4(7):103663. doi: 10.1016/j.jscai.2025.103663. eCollection 2025 Jul.
Current guidelines recommend a strategy of clinical surveillance (CS) for patients with asymptomatic severe aortic stenosis and normal left ventricular ejection fraction.
PubMed, Embase, and ClinicalTrials.gov were searched through November 2024 for randomized controlled trials (RCTs) and observational studies comparing surgical aortic valve replacement or transcatheter aortic valve replacement with CS in patients with asymptomatic severe aortic stenosis.
Sixteen eligible studies (12 observational studies and 4 RCTs) were identified, with a total of 3919 patients in the observational studies and 1427 patients in the RCTs. In the pooled analyses combining observational studies and RCTs, aortic valve replacement (AVR) was associated with significantly reduced all-cause mortality (incidence rate ratio [IRR], 0.42; 95% CI, 0.31-0.58; < .01; = 72%), cardiovascular mortality (IRR, 0.46; 95% CI, 0.28-0.78; < .01; = 68%), and unplanned cardiovascular or heart failure (HF)-related hospitalization (IRR, 0.34; 95% CI, 0.21-0.55; < .01; = 50%). In 12 observational studies, AVR was associated with significantly lower rates of all-cause mortality (IRR, 0.36; 95% CI, 0.27-0.49; < .01; = 65%), and cardiovascular mortality (IRR, 0.33; 95% CI, 0.16-0.70; < .01; = 71%) compared with CS. In 4 RCTs, there was no significant difference in all-cause or cardiovascular mortality, but AVR was associated with a significant reduction in unplanned cardiovascular or HF hospitalization (IRR, 0.42; 95% CI, 0.26-0.65; < .01; = 27%) and stroke (IRR, 0.63; 95% CI, 0.40-0.98 = .04; = 0%).
Data from observational studies and recent RCTs suggest that a strategy of preemptive AVR is associated with improved survival and lower rates of unplanned cardiovascular or HF-related hospitalizations and stroke compared to CS.
当前指南推荐对无症状重度主动脉瓣狭窄且左心室射血分数正常的患者采用临床监测（CS）策略。
检索截至2024年11月的PubMed、Embase和ClinicalTrials.gov，查找比较无症状重度主动脉瓣狭窄患者接受外科主动脉瓣置换术或经导管主动脉瓣置换术与临床监测的随机对照试验（RCT）和观察性研究。
共纳入16项合格研究（12项观察性研究和4项RCT），观察性研究中有3919例患者，RCT中有1427例患者。在综合观察性研究和RCT的汇总分析中，主动脉瓣置换术（AVR）与全因死亡率显著降低相关（发生率比[IRR]，0.42；95%置信区间[CI]，0.31 - 0.58；P <.01；I² = 72%）、心血管死亡率（IRR，0.46；95% CI，0.28 - 0.78；P <.01；I² = 68%）以及非计划性心血管或心力衰竭（HF）相关住院率（IRR，0.34；95% CI，0.21 - 0.55；P <.01；I² = 50%）。在12项观察性研究中，与临床监测相比，AVR与全因死亡率（IRR，0.36；95% CI，0.27 - 0.49；P <.01；I² = 65%）和心血管死亡率（IRR，0.33；95% CI，0.16 - 0.70；P <.01；I² = 71%）显著降低相关。在4项RCT中，全因或心血管死亡率无显著差异，但AVR与非计划性心血管或HF住院率显著降低（IRR，0.42；95% CI，0.26 - 0.65；P <.01；I² = 27%）和卒中（IRR，0.63；95% CI，0.40 - 0.98；P =.04；I² = 0%）相关。
观察性研究和近期RCT的数据表明，与临床监测相比，抢先进行AVR策略与生存率提高、非计划性心血管或HF相关住院率及卒中发生率降低相关。
