Early aortic valve intervention in asymptomatic severe aortic stenosis: a clinical dilemma in evolution

Abstract

The management of asymptomatic severe aortic stenosis (AS) has traditionally relied on watchful waiting until the onset of symptoms or left ventricular dysfunction. However, the FDA’s approval of transcatheter aortic valve replacement (TAVR) with the Sapien 3 platform in May 2025, based on the EARLY TAVR trial, has intensified the debate over early intervention. This Viewpoint synthesizes evidence from randomized trials (RECOVERY, AVATAR, EVOLVED, EARLY TAVR) and registries (HAVEC, VALVENOR) to evaluate the role of early aortic valve replacement (AVR). Early intervention is associated with reductions in combined endpoints of cardiovascular hospitalizations, stroke, and mortality in selected patients, with the EARLY TAVR demonstrating a 50% reduction in major cardiovascular events. Nonetheless, evidence remains inconsistent, particularly in low-risk populations, as the EVOLVED trial showed no mortality benefit in patients with myocardial fibrosis, warranting cautious interpretation. A conservative surveillance strategy remains appropriate in some cases, supported by the low annual risk of sudden death (i.e. 0.65% per year) and ongoing concerns over valve durability and procedural risks. Given the heterogeneity of patient and valve phenotypes, a personalized risk assessment, combining clinical evaluation, biomarkers (troponin, BNP), and imaging (echocardiography, CMR), is proposed to identify high-risk patients and optimize the timing of early intervention. Expert heart team guidance is essential, and routine early intervention cannot yet be recommended. Further research is needed to refine strategies and improve outcomes in this evolving clinical landscape. © The Author(s) 2025. Published by Oxford University Press on behalf of the European Society of Cardiology.