Journal of the Practice of Cardiovascular Sciences

REVIEW ARTICLE
Year
: 2020  |  Volume : 6  |  Issue : 1  |  Page : 16--17

Early surgery or conservative care for asymptomatic aortic stenosis (The RECOVERY trial)


Nayani Makkar 
 Department of Cardiology, AIIMS, New Delhi, India

Correspondence Address:
Nayani Makkar
Department of Cardiology, AIIMS, New Delhi
India

Abstract

The Early Surgery or Conservative Care for Asymptomatic Aortic Stenosis (The RECOVERY Trial) was an open-label, parallel-group trial that recruited 145 patients with very severe aortic stenosis with a mean gradient of 50 mmHg or greater across the aortic valve). It showed that early surgery should be considered the modality of choice in patients with asymptomatic severe aortic stenosis considering the high rate of progression of the disease to a symptomatic state and amelioration of the risk of sudden death with early surgery.



How to cite this article:
Makkar N. Early surgery or conservative care for asymptomatic aortic stenosis (The RECOVERY trial).J Pract Cardiovasc Sci 2020;6:16-17


How to cite this URL:
Makkar N. Early surgery or conservative care for asymptomatic aortic stenosis (The RECOVERY trial). J Pract Cardiovasc Sci [serial online] 2020 [cited 2020 Jul 4 ];6:16-17
Available from: http://www.j-pcs.org/text.asp?2020/6/1/16/282802


Full Text



Kang DH, Park SJ, Lee SA, Lee S, Kim DH, Kim HK, et al. Early Surgery or Conservative Care for Asymptomatic Aortic Stenosis. N Engl J Med 2020;382:111-9.

The emergence of aortic stenosis as the most prevalent valvular disease, particularly in the developed world, has been attributed to the aging population.[1] While aortic valve replacement (AVR) by surgical or transcatheter techniques remains the standard of care in patients with symptomatic severe or very severe aortic stenosis, there is less consensus regarding the approach to such asymptomatic lesions. One-third to one-half of patients with severe aortic stenosis are asymptomatic at the time of initial diagnosis.[2] Although, on average, the stenosis in symptomatic patients is more severe than in those without symptoms, there is a significant overlap in all indices of severity in the two groups.[3] Prior studies on the subject have been observational and have succeeded in demonstrating the high risk of progression to symptomatic aortic stenosis, particularly in patients with more severe disease as estimated by high Doppler aortic jet velocities.[4] The RECOVERY trial[5] sought to elucidate the role of early surgery in patients with asymptomatic severe or very severe aortic stenosis.

The study was an open-label, parallel-group trial that recruited 145 patients between 20 and 80 years of age with very severe aortic stenosis (defined as an aortic valve area of 0.75 cm2 or less with either a peak jet velocity of 4.5 m/s or greater or a mean gradient of 50 mmHg or greater across the aortic valve). Patients with symptoms, left ventricular ejection fraction <50%, significant aortic regurgitation, or multivalvular disease and patients with significant medical comorbidities that precluded surgery were excluded. Exercise testing was used selectively to stratify patients with nonspecific symptoms. A primary endpoint of operative mortality (death during or within 30 days after the surgery) or cardiovascular mortality within the follow-up period of 4 years after the last patient recruitment was considered.

Over a median follow-up period of 6.1 years in the conservative group and 6.2 years in the early surgery group, the trial demonstrated a significant reduction in the primary endpoint in the early intervention arm. In addition, all-cause mortality was significantly lower in the early surgery group. Notably, it was found that the risk of sudden cardiac death (7 of 11 mortalities, 63.6%) increased in patients managed conservatively even before the first onset of symptoms. In addition, in patients assigned to conservative management, the majority of patients eventually underwent AVR, with a higher operative mortality than for patients managed with early surgery.

In spite of these merits to the above study, it suffered from certain limitations. First, the low surgical risk of the study population contributed to the extremely low operative mortality of the early surgery group. These results may be harder to reproduce in a real-world scenario. Ostensibly, the risk may be offset by the use of transcatheter techniques, however, the use of these methods in this select group merits further evaluation.

Second, there was a high rate of surgical or transcatheter AVR (53 of 72, 74%) in the conservative arm during the follow-up period. Plausibly, given the natural history of the disease and the selective use of techniques such as exercise testing and follow-up echocardiography, the remainder of patients in the conservative group may have benefitted from consideration for AVR.

Furthermore, the included patients had a mean age of 64.2 years, with rheumatic aortic stenosis accounting for only 9 (6%) of recruited patients. There are limitations, thus extrapolating data to developing countries with a relatively higher prevalence of rheumatic aortic stenosis in a younger population, who may fare worse with mechanical prosthetic valves than native disease. Finally, per trial protocol, a lack of blinding and a relatively small number of recruited patients and endpoint events may have influenced the obtained results.

Regardless, the trial succeeds in demonstrating that early surgery in the select group of patients with asymptomatic very severe aortic stenosis should be considered the modality of choice considering not just the high rate of eventual progression of the disease to a symptomatic state but also an amelioration of the risk of sudden death with early surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J 2017;38:2739-91.
2Généreux P, Stone GW, O'Gara PT, Marquis-Gravel G, Redfors B, Giustino G, et al. Natural history, diagnostic approaches, and therapeutic strategies for patients with asymptomatic severe aortic stenosis. J Am Coll Cardiol 2016;67:2263-88.
3Dal-Bianco JP, Khandheria BK, Mookadam F, Gentile F, Sengupta PP. Management of asymptomatic severe aortic stenosis. J Am Coll Cardiol 2008;52:1279-92.
4Capoulade R, Le Ven F, Clavel MA, Dumesnil JG, Dahou A, Thébault C, et al. Echocardiographic predictors of outcomes in adults with aortic stenosis. Heart 2016;102:934-42.
5Kang DH, Park SJ, Lee SA, Lee S, Kim DH, Kim HK, et al. Early surgery or conserv ative care for asymptomatic aortic stenosis. N Engl J Med 2020;382:111-9.