Marko Banovic1,2, Svetozar Putnik1,3, Martin Penicka4, Gheorghe Doros5, Marek A Deja6, Radka Kockova7, Martin Kotrc7, Sigita Glaveckaite8, Hrvoje Gasparovic9, Nikola Pavlovic10, Lazar Velicki11,12, Stefano Salizzoni13, Wojtek Wojakowski14, Guy Van Camp4, Serge D Nikolic15, Bernard Iung16, Jozef Bartunek4. 1. Belgrade Medical School, University of Belgrade, Serbia (M.B., S.P.). 2. Cardiology Department (M.B.), University Clinical Center of Serbia, Belgrade. 3. Cardiac-Surgery Department (S.P.), University Clinical Center of Serbia, Belgrade. 4. Cardiovascular Center, OLV Hospital, Aalst, Belgium (M.P., G.V.C., J.B.). 5. Boston University School of Public Health, Department of Biostatistics, MA (G.D.). 6. Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland (M.A.D.). 7. Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (R.K., M.K.). 8. Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Lithuania (S.G.). 9. Department of Cardiac Surgery, University of Zagreb School of Medicine and University Hospital Center Zagreb, Croatia (H.G.). 10. University Hospital Center Sestre Milosrdnice, Zagreb, Croatia (N.P.). 11. Faculty of Medicine, University of Novi Sad, Serbia (L.V.). 12. Institute of Cardiovascular Diseases Vojvodina, Sremska Kamenica, Serbia (L.V.). 13. Division of Cardiosurgery, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Italy (S.S.). 14. Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland (W.W.). 15. CorDynamix, Redwood City, CA (S.N.D.). 16. Cardiology Department, Bichat Hospital APHP and Universite de Paris, France (B.I.).
Abstract
BACKGROUND: Surgical aortic valve replacement (SAVR) represents a class I indication in symptomatic patients with severe aortic stenosis (AS). However, indications for early SAVR in asymptomatic patients with severe AS and normal left ventricular function remain debated. METHODS: The AVATAR trial (Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis) is an investigator-initiated international prospective randomized controlled trial that evaluated the safety and efficacy of early SAVR in the treatment of asymptomatic patients with severe AS, according to common criteria (valve area ≤1 cm2 with aortic jet velocity >4 m/s or a mean transaortic gradient ≥40 mm Hg), and with normal left ventricular function. Negative exercise testing was mandatory for inclusion. The primary hypothesis was that early SAVR would reduce the primary composite end point of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with a conservative strategy according to guidelines. The trial was designed as event-driven to reach a minimum of 35 prespecified events. The study was performed in 9 centers in 7 European countries. RESULTS: Between June 2015 and September 2020, 157 patients (mean age, 67 years; 57% men) were randomly allocated to early surgery (n=78) or conservative treatment (n=79). Follow-up was completed in May 2021. Overall median follow-up was 32 months: 28 months in the early surgery group and 35 months in the conservative treatment group. There was a total of 39 events, 13 in early surgery and 26 in the conservative treatment group. In the early surgery group, 72 patients (92.3%) underwent SAVR with operative mortality of 1.4%. In an intention-to-treat analysis, patients randomized to early surgery had a significantly lower incidence of primary composite end point than those in the conservative arm (hazard ratio, 0.46 [95% CI, 0.23-0.90]; P=0.02). There was no statistical difference in secondary end points, including all-cause mortality, first heart failure hospitalizations, major bleeding, or thromboembolic complications, but trends were consistent with the primary outcome. CONCLUSIONS: In asymptomatic patients with severe AS, early surgery reduced a primary composite of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with conservative treatment. This randomized trial provides preliminary support for early SAVR once AS becomes severe, regardless of symptoms. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02436655.
BACKGROUND: Surgical aortic valve replacement (SAVR) represents a class I indication in symptomatic patients with severe aortic stenosis (AS). However, indications for early SAVR in asymptomatic patients with severe AS and normal left ventricular function remain debated. METHODS: The AVATAR trial (Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis) is an investigator-initiated international prospective randomized controlled trial that evaluated the safety and efficacy of early SAVR in the treatment of asymptomatic patients with severe AS, according to common criteria (valve area ≤1 cm2 with aortic jet velocity >4 m/s or a mean transaortic gradient ≥40 mm Hg), and with normal left ventricular function. Negative exercise testing was mandatory for inclusion. The primary hypothesis was that early SAVR would reduce the primary composite end point of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with a conservative strategy according to guidelines. The trial was designed as event-driven to reach a minimum of 35 prespecified events. The study was performed in 9 centers in 7 European countries. RESULTS: Between June 2015 and September 2020, 157 patients (mean age, 67 years; 57% men) were randomly allocated to early surgery (n=78) or conservative treatment (n=79). Follow-up was completed in May 2021. Overall median follow-up was 32 months: 28 months in the early surgery group and 35 months in the conservative treatment group. There was a total of 39 events, 13 in early surgery and 26 in the conservative treatment group. In the early surgery group, 72 patients (92.3%) underwent SAVR with operative mortality of 1.4%. In an intention-to-treat analysis, patients randomized to early surgery had a significantly lower incidence of primary composite end point than those in the conservative arm (hazard ratio, 0.46 [95% CI, 0.23-0.90]; P=0.02). There was no statistical difference in secondary end points, including all-cause mortality, first heart failure hospitalizations, major bleeding, or thromboembolic complications, but trends were consistent with the primary outcome. CONCLUSIONS: In asymptomatic patients with severe AS, early surgery reduced a primary composite of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with conservative treatment. This randomized trial provides preliminary support for early SAVR once AS becomes severe, regardless of symptoms. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02436655.
Authors: Theodor Fischlein; Elena Caporali; Federico M Asch; Ferdinand Vogt; Francesco Pollari; Thierry Folliguet; Utz Kappert; Bart Meuris; Malakh L Shrestha; Eric E Roselli; Nikolaos Bonaros; Olivier Fabre; Pierre Corbi; Giovanni Troise; Martin Andreas; Frederic Pinaud; Steffen Pfeiffer; Sami Kueri; Erwin Tan; Pierre Voisine; Evaldas Girdauskas; Filip Rega; Julio García-Puente; Laurent De Kerchove; Roberto Lorusso Journal: Front Cardiovasc Med Date: 2022-02-18
Authors: Vladimir Shvartz; Maria Sokolskaya; Andrey Petrosyan; Artak Ispiryan; Sergey Donakanyan; Leo Bockeria; Olga Bockeria Journal: Pathophysiology Date: 2022-03-09