Aortic Valve ReplAcemenT versus Conservative Treatment in Asymptomatic SeveRe Aortic Stenosis - AVATAR

Contribution To Literature:

The AVATAR trial showed that early AVR was beneficial at preventing adverse events among patients with asymptomatic severe aortic stenosis.

Description:

The goal of the trial was to evaluate aortic valve replacement (AVR) compared with conservative therapy among patients with asymptomatic severe aortic stenosis.

Study Design

  • Randomization
  • Parallel

Participants with asymptomatic severe aortic stenosis were randomized to early surgery (n = 78) versus conservative therapy (n = 79).

  • Total number of enrollees: 157
  • Duration of follow-up: 32 months
  • Mean patient age: 67 years
  • Percentage female: 43%
  • Percentage with diabetes: 23%

Inclusion criteria:

  • Patients at least 18 years of age with asymptomatic severe aortic stenosis
  • Asymptomatic status confirmed by exercise testing
  • Society of Thoracic Surgeons-Predicted Risk of Mortality (STS-PROM) score <8%

Exclusion criteria:

  • Positive exercise test
  • Left ventricular ejection fraction <50%
  • Very severe aortic stenosis with peak velocity >5.5 m/s
  • Need for aortic stenosis
  • Previous coronary artery bypass grafting or heart valve surgery
  • Major comorbidities
  • Life expectancy <3 years

Other salient features/characteristics:

  • In the early surgery group, 92.3% underwent surgical AVR

Principal Findings:

The primary outcome, all-cause death, heart failure, acute myocardial infarction, or stroke, occurred at a rate of 15.2% in the early surgery group compared with 34.7% in the conservative therapy group (p = 0.02).

Secondary outcomes:

  • Thirty-day mortality: 1.4% in the early surgery group vs. 4% in the conservative therapy group (p = not significant [NS])
  • Heart failure hospitalization: 9.5% in the early surgery group vs. 20.1% in the conservative therapy group (p = NS)

Interpretation:

Among patients with asymptomatic severe aortic stenosis, early surgery was beneficial. Early surgery compared with conservative therapy was associated with a significantly lower incidence of composite adverse events over a median follow-up of 32 months. While these findings are interesting, a significant limitation of this trial is the small sample size.

References:

Doros G, Deja MA, Kockova R, et al., on behalf of the AVATAR trial investigators. Aortic Valve ReplAcemenT versus Conservative Treatment in Asymptomatic SeveRe Aortic Stenosis: The AVATAR Trial. Circulation 2021;Nov 13:[Epub ahead of print].

Presented by Dr. Marko Banovic at the American Heart Association Virtual Annual Scientific Sessions (AHA 2021), November 13, 2021.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and ACS, Interventions and Structural Heart Disease

Keywords: Acute Coronary Syndrome, AHA21, AHA Annual Scientific Sessions, Aortic Valve Stenosis, Cardiac Surgical Procedures, Exercise Test, Heart Failure, Heart Valve Diseases, Heart Valve Prosthesis, Myocardial Infarction, Stroke


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