, JACC: ADVANCES VOL. 4, NO. 10, 2025
© 2025 THE AUTHORS. PUBLISHED BY ELSEVIER ON BEHALF OF THE AMERICAN
COLLEGE OF CARDIOLOGY FOUNDATION. THIS IS AN OPEN ACCESS ARTICLE UNDER
THE CC BY LICENSE (http://creativecommons.org/licenses/by/4.0/).
STATE-OF-THE-ART REVIEW
Early Intervention vs Conservative
Management in Severe Asymptomatic
Aortic Stenosis
A Critical Review of Randomized Evidence
Victor Dayan, MD, PHD,a Mateo Marin-Cuartas, MD,b Raffaele De Caterina, MD,c Suzanne De Waha, MD,b
Nicolas M. Van Mieghem, MD,d Michael A. Borger, MD, PHD,b Robert O. Bonow, MD, MS,e
Deepak L. Bhatt, MD, MPH, MBAf
ABSTRACT
Aortic stenosis (AS) is a progressive disease that may remain asymptomatic despite underlying myocardial damage.
Management of asymptomatic severe AS remains controversial, especially in the current era of safer surgical and
transcatheter valve replacement. This critical review examines 4 randomized controlled trials—AVATAR (Aortic Valve
Replacement Vs Conservative Treatment in Asymptomatic Severe Aortic Stenosis), RECOVERY (Randomized Comparison
of Early Surgery vs Conventional Treatment in Very Severe Aortic Stenosis), EARLY TAVR (Evaluation of TAVR Compared
to Surveillance for Patients with Asymptomatic Severe Aortic Stenosis), and EVOLVED (Early Valve Replacement Guided
by Biomarkers of Left Ventricular Decompensation in Asymptomatic Patients with Severe Aortic Stenosis)—comparing
early aortic valve replacement with conservative management. While early intervention reduces composite endpoints
involving heart failure hospitalization, individual trials have not demonstrated consistent mortality or stroke benefits.
Importantly, sudden cardiac death was rare across all trials, and close surveillance appeared to be a key determinant of
outcomes in the conservative arms. Differences in surveillance intensity, trial populations, and valve types limit pooled
interpretations. Current evidence supports a tailored approach: conservative management is reasonable when reliable
follow-up can be ensured, while early aortic valve replacement may benefit selected patients. Ongoing trials will help
clarify long-term outcomes, optimal timing, and risk stratification strategies in asymptomatic AS.
(JACC Adv. 2025;4:102178) © 2025 The Authors. Published by Elsevier on behalf of the American College of Cardiology
Foundation. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
A ortic stenosis (AS) is a progressive disease
primarily caused by degenerative calcifica-
tion, bicuspid aortic valve disease, and, less
commonly, rheumatic valve disease.1 The progres-
increased afterload, resulting in compensatory left
ventricular (LV) hypertrophy. The combination of hy-
pertrophy, myocardial fibrosis, and ischemia may
explain the development of symptoms as the severity
sive reduction in effective orifice area leads to of AS progresses, but the risk of sudden cardiac death
From the aCentro Cardiovascular Universitario, Universidad de la Republica, Montevideo, Uruguay; bUniversity Department of
Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany; cChair of Cardiology, University of Pisa and Cardiology Division 1, Pisa
University Hospital, Pisa, Italy; dDepartment of Interventional Cardiology, Thoraxcenter, Cardiovascular Institute, Erasmus
University Medical Center, Rotterdam, Netherlands; eNorthwestern University Feinberg School of Medicine, Chicago, Illinois,
USA; fMount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, USA.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’
institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more
information, visit the Author Center.
Manuscript received May 23, 2025; revised manuscript received August 5, 2025, accepted August 12, 2025.
ISSN 2772-963X https://doi.org/10.1016/j.jacadv.2025.102178
© 2025 THE AUTHORS. PUBLISHED BY ELSEVIER ON BEHALF OF THE AMERICAN
COLLEGE OF CARDIOLOGY FOUNDATION. THIS IS AN OPEN ACCESS ARTICLE UNDER
THE CC BY LICENSE (http://creativecommons.org/licenses/by/4.0/).
STATE-OF-THE-ART REVIEW
Early Intervention vs Conservative
Management in Severe Asymptomatic
Aortic Stenosis
A Critical Review of Randomized Evidence
Victor Dayan, MD, PHD,a Mateo Marin-Cuartas, MD,b Raffaele De Caterina, MD,c Suzanne De Waha, MD,b
Nicolas M. Van Mieghem, MD,d Michael A. Borger, MD, PHD,b Robert O. Bonow, MD, MS,e
Deepak L. Bhatt, MD, MPH, MBAf
ABSTRACT
Aortic stenosis (AS) is a progressive disease that may remain asymptomatic despite underlying myocardial damage.
Management of asymptomatic severe AS remains controversial, especially in the current era of safer surgical and
transcatheter valve replacement. This critical review examines 4 randomized controlled trials—AVATAR (Aortic Valve
Replacement Vs Conservative Treatment in Asymptomatic Severe Aortic Stenosis), RECOVERY (Randomized Comparison
of Early Surgery vs Conventional Treatment in Very Severe Aortic Stenosis), EARLY TAVR (Evaluation of TAVR Compared
to Surveillance for Patients with Asymptomatic Severe Aortic Stenosis), and EVOLVED (Early Valve Replacement Guided
by Biomarkers of Left Ventricular Decompensation in Asymptomatic Patients with Severe Aortic Stenosis)—comparing
early aortic valve replacement with conservative management. While early intervention reduces composite endpoints
involving heart failure hospitalization, individual trials have not demonstrated consistent mortality or stroke benefits.
Importantly, sudden cardiac death was rare across all trials, and close surveillance appeared to be a key determinant of
outcomes in the conservative arms. Differences in surveillance intensity, trial populations, and valve types limit pooled
interpretations. Current evidence supports a tailored approach: conservative management is reasonable when reliable
follow-up can be ensured, while early aortic valve replacement may benefit selected patients. Ongoing trials will help
clarify long-term outcomes, optimal timing, and risk stratification strategies in asymptomatic AS.
(JACC Adv. 2025;4:102178) © 2025 The Authors. Published by Elsevier on behalf of the American College of Cardiology
Foundation. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
A ortic stenosis (AS) is a progressive disease
primarily caused by degenerative calcifica-
tion, bicuspid aortic valve disease, and, less
commonly, rheumatic valve disease.1 The progres-
increased afterload, resulting in compensatory left
ventricular (LV) hypertrophy. The combination of hy-
pertrophy, myocardial fibrosis, and ischemia may
explain the development of symptoms as the severity
sive reduction in effective orifice area leads to of AS progresses, but the risk of sudden cardiac death
From the aCentro Cardiovascular Universitario, Universidad de la Republica, Montevideo, Uruguay; bUniversity Department of
Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany; cChair of Cardiology, University of Pisa and Cardiology Division 1, Pisa
University Hospital, Pisa, Italy; dDepartment of Interventional Cardiology, Thoraxcenter, Cardiovascular Institute, Erasmus
University Medical Center, Rotterdam, Netherlands; eNorthwestern University Feinberg School of Medicine, Chicago, Illinois,
USA; fMount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, USA.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’
institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more
information, visit the Author Center.
Manuscript received May 23, 2025; revised manuscript received August 5, 2025, accepted August 12, 2025.
ISSN 2772-963X https://doi.org/10.1016/j.jacadv.2025.102178
