Aortic stenosis; Aortic valve replacement; Early intervention; Risk stratification; Transcatheter aortic valve implantation; Surgery; Cardiology and Cardiovascular Medicine
Abstract :
[en] The management of asymptomatic severe aortic stenosis (AS) has traditionally relied on watchful waiting until the onset of symptoms or left ventricular dysfunction. However, the FDA’s approval of transcatheter aortic valve replacement (TAVR) with the Sapien 3 platform in May 2025, based on the EARLY TAVR trial, has intensified the debate over early intervention. This Viewpoint synthesizes evidence from randomized trials (RECOVERY, AVATAR, EVOLVED, EARLY TAVR) and registries (HAVEC, VALVENOR) to evaluate the role of early aortic valve replacement (AVR). Early intervention is associated with reductions in combined endpoints of cardiovascular hospitalizations, stroke, and mortality in selected patients, with the EARLY TAVR demonstrating a 50% reduction in major cardiovascular events. Nonetheless, evidence remains inconsistent, particularly in low-risk populations, as the EVOLVED trial showed no mortality benefit in patients with myocardial fibrosis, warranting cautious interpretation. A conservative surveillance strategy remains appropriate in some cases, supported by the low annual risk of sudden death (i.e. 0.65% per year) and ongoing concerns over valve durability and procedural risks. Given the heterogeneity of patient and valve phenotypes, a personalized risk assessment, combining clinical evaluation, biomarkers (troponin, BNP), and imaging (echocardiography, CMR), is proposed to identify high-risk patients and optimize the timing of early intervention. Expert heart team guidance is essential, and routine early intervention cannot yet be recommended. Further research is needed to refine strategies and improve outcomes in this evolving clinical landscape.
Disciplines :
Cardiovascular & respiratory systems
Author, co-author :
Lancellotti, Patrizio ; Université de Liège - ULiège > Département des sciences cliniques > Cardiologie - Pathologie spéciale et réhabilitation
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Cosyns, Bernard; Centrum Voor Harten Vaatziekten (CHVZ), Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium ; In Vivo Cellular and Molecular Imaging (ICMI) Center, Vrije Universiteit Brussel (VUB), Brussels, Belgium
Garbi, Madalina; Royal Papworth Hospital, Cambridge University Health Partners, Cambridge, United Kingdom
Hong, Geu-Ru ; Cardiology Division, Severance Cardiovascular Hospital, Yonsei University College of Medicine, South Korea
Hanzevacki, Jadranka Separovic; Department of Cardiovascular Diseases, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
Moscarelli, Marco ; Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom ; Department of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care&Research, Palermo, Italy
Sugimoto, Tadafumi; Department of Cardiology, Nagoya City University Mirai Kousei Hospital, Nagoya, Japan
Donal, Erwan ; Université de Rennes, CHU Rennes, Service de Cardiologie Inserm, LTSI-UMR 1099, Rennes, France
Fattouch, Khalil ; Department of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care&Research, Palermo, Italy
Habib, Gilbert; Cardiology Department, APHM, La Timone Hospital, Marseille, France ; 2 Aix Marseille University, IRD, APHM, MEPHI, IHU-Méditerraneée Infection, France
Vannan, Mani; Marcus Heart Valve Center, Piedmont Heart Institute, Atlanta, United States
Pibarot, Philippe ; Quebec Heart and Lung Institute, Université Laval, Québec City, Canada
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