J Cardoso

Objective Timing of intervention for patients with asymptomatic severe aortic stenosis (AS) remains controversial. To compare the outcomes of early aortic valve replacement (AVR) versus watchful waiting (WW) in patients with asymptomatic severe AS. Methods We systematically searched PubMed, Embase and Cochrane databases, in December 2021, for studies comparing early AVR with WW in the treatment of asymptomatic severe AS. Random-effects meta-analysis was performed. Results Twelve studies were included in which two were randomised clinical trials. A total of 4130 patients were included, providing a 1092 pooled death events. Our meta-analysis showed a significantly lower all-cause mortality for the early AVR compared with WW group, although with a high amount of heterogeneity between studies in the magnitude of the effect (pooled OR 0.40; 95% CI 0.35 to 0.45, pConclusions This study suggests that for patients with asymptomatic severe AS an early surgical intervention compared with a conservative WW strategy was associated with a lower heart failure hospitalisation and a similar rate of stroke or myocardial infarction, although with significant risk of bias. PROSPERO registration number CRD42021291144.

Aortic stenosis (AS) is the most common valvular disease in developed countries. Specific timing of intervention for asymptomatic patients with severe aortic stenosis and preserved ejection fraction remains controversial. To compare the outcomes of early aortic valve replacement (AVR) versus watchful waiting (WW) in asymptomatic AS patients with preserved ejection. We systematically searched PubMed, Embase and Cochrane databases, in November 2021, for both interventional or observational studies comparing early-AVR with WW in the treatment of asymptomatic severeAS with preserved ejection fraction criteria. Random-effects meta-analysis was performed. Eight studies were included in which two were randomized clinical trials. A total of 2672 patients were included, providing a 642 pooled death events (327 in early-AVR and 941 in watchful waiting). In our meta-analysis, early-AVR revealed a significant lower all-cause mortality (pooled OR, 0.39; 95% CI [0.30, 0.51], P2=47%). Additionally, the early-AVR group presented a lower rate of cardiovascular mortality (pooled OR, 0.33; 95% CI [0.19, 0.56], P2=64%). Both strategies had similar rate of stroke (pooled OR, 1.30; 95% CI [0.39, 4.27], P=0.67; I²=0%) and myocardial infarction (pooled OR, 0.49; 95% CI [0.14, 1.78], P=0.28; I²=0%). Heart Failure hospitalizations presented a lower trend early-AVR group (pooled OR, 0.22; 95% CI [0.05, 1.08], P=0.36; I²=36%). Our pooled data suggests that early-AVR strategy is preferable for asymptomatic severe AS patients with preserved ejection fraction. Type of funding sources: None. Figure 1

Tricuspid Regurgitation (TR) is common in patients with severe mitral disease. However, the evidence is insufficient to inform a decision about whether to perform prophylactic tricuspid-valve repair during mitral-valve surgery in patients who have moderate TR or less-than-moderate regurgitation. To compare the outcomes of concomitant tricuspid repair in mitral valve surgery versus no concomitant tricuspid repair in less-than-severe TR patients. We systematically searched PubMed, Embase and Cochrane databases, in December 2021, for interventional studies comparing concomitant tricuspid repair in mitral valve surgery versus no tricuspid intervention. Random-effects meta-analysis was performed. Four randomised trials were included, providing a total of 651 patients (323 in prophylactic tricuspid intervention group and 328 patients in conservative group). Our meta-analysis showed a similar all-cause mortality for concomitant prophylactic tricuspid repair compared with no tricuspid intervention (pooled OR, 0.54; 95% CI [0.25, 1.15], P=0.11; I²=0%). Additionally, there is a similar New York Heart Association (NYHA) III–IV classes in both groups, despite a lower trend in the tricuspid intervention group (pooled OR, 0.63; 95% CI [0.38, 1.06], P=0.08; I²=0%) (Figure 3). However, there was a significant lower progression of TR (pooled OR, 0.06; 95% CI [0.02, 0.24], P2=0%) and moderate-severe TR (pooled OR, 0.23; 95% CI [0.11, 0.46], P2=27%). Our pooled analysis suggests that a tricuspid-valve repair at the time of mitral-valve surgery in patients with moderate or less-than-moderate TR does not impact perioperative or postoperative all-cause mortality, despite reducing TR severity and progression of TR following intervention. Type of funding sources: None. Figure 1 Figure 2