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RECOVERY: Benefit of early surgery in asymptomatic severe aortic stenosis

Presented by
Prof. Duk-Hyun Kang, Asan Medical Center, South Korea
AHA 2019
Results of the RECOVERY trial demonstrate that early pre-emptive aortic valve replacement (AVR) is better for asymptomatic patients with severe aortic stenosis (AS) than conservative management for the outcomes of operative or cardiovascular death, as well as death from any cause [1].

It has been unclear to date as to whether the risk of death outweighs the risk of AVR-related death in asymptomatic AS patients, and the ESC2017 guidelines currently recommend watchful observance. However, there has never been a randomised trial to support this approach. Prof. Duk-Hyun Kang (Asan Medical Center, South Korea) presented the 8-year follow-up results of The Randomized Comparison of Early Surgery versus Conventional Treatment in Very Severe Aortic Stenosis (RECOVERY) study. RECOVERY was a prospective, multicentre, open-label, randomised trial in which asymptomatic patients with severe AS were randomly assigned to early surgery (n=73) or to conventional treatment (n=72). The primary endpoint of the trial was a composite of peri-operative mortality or cardiovascular death. The major secondary endpoint was death from any cause.

Patients randomised to early surgery received AVR within 2 months (n=69 intention-to-treat), while patients in the conventional treatment arm were treated according to the current guidelines (n=52 intention-to-treat). Patients who were assigned to conventional care were referred for AVR if they became symptomatic, had a left ventricle ejection fraction <0.50, or an increase in peak aortic velocity >0.5 m/s per year.

In the pre-emptive surgery group, the rate of peri-operative death was 1.4% at both 4 and 8 years of follow-up compared with 5.7% at 4 years and 25.5% at 8 years in the conventional treatment arm (P=0.003; see Figure). The rate of all-cause mortality was also higher in the conventional treatment arm compared with the early surgery group (9.7% vs 4.1% at 4 years and 31.8% vs 10.2% at 8 years, respectively; P=0.018; see Figure). The evidence from this trial strongly supports early AVR intervention for asymptomatic patients with severe aortic stenosis.

Figure: Primary and secondary endpoints of the RECOVERY trial [1]

1. Kang D-H, et al. RECOVERY: Early Surgery versus Conventional Management for Asymptomatic Severe Aortic Stenosis. LBS04, AHA Scientific Sessions 2019, 14-18 November, Philadelphia, USA.

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