Early surgical aortic valve replacement (SAVR) led to a lower incidence of operative mortality or cardiovascular-related death at 10 years in patients with very severe aortic stenosis (AS), according to an extended follow-up of the RECOVERY trial published March 25 in NEJM.

Duk-Hyun Kang, MD, PhD, et al., randomly assigned 145 asymptomatic patients with very severe AS (defined as an aortic-valve area of ≤0.75 cm2 with a peak aortic jet velocity of ≥4.5 m per second) 1:1 to undergo early surgery or receive conservative care from July 2021 through April 2015. Data collection ended in May 2025.

The primary endpoint was a composite of death from cardiovascular causes during a 10-year follow-up period, or operative mortality during surgery or within 30 days after surgery. Of note, of the 72 patients assigned to receive conservative care, 61 (85%) underwent either SAVR (59 patients) or TAVR (2 patients) during follow-up.

Results of the multicenter, open-label trial showed that in an intention-to-treat analysis, the primary endpoint was met in two of 73 patients (3%) in the early surgery group and 17 of 72 patients (24%) in the conservative care group (hazard ratio [HR], 0.10; p=0.002). Additionally, at the 10-year follow-up, the cumulative incidence of operative mortality or cardiovascular death was 1% in the early-surgery group, compared with 19% in the conservative-care group.

All-cause mortality occurred in 11 patients (15%) in the early surgery group and in 23 patients (32%) in the conservative care group (HR, 0.42).

The authors note several study limitations, including their definition of severe AS, potential ascertainment bias and lack of exercise stress testing routines.

Kang and colleagues write that although "randomized trials comparing early aortic valve replacement with conservative care in asymptomatic patients with severe [AS] have shown conflicting results," their study showed that early surgical aortic valve replacement"…led to a lower incidence of a composite primary end point of operative mortality or death from cardiovascular causes over a period of 10 years as compared with conservative care."