Key Points:
- Over a decade of follow-up, early surgical aortic valve replacement (AVR) continued to confer a substantial survival advantage over conservative management in asymptomatic patients with very severe aortic stenosis (AS).
- Building on the original 2020 results, early surgery reduced cardiovascular mortality by 90% and all-cause mortality by more than half, without any operative deaths—confirming the long-term durability and safety of an early-intervention strategy.
The RECOVERY Trial (NCT01161732), led by Duk-Hyun Kang and investigators from Asan Medical Center, provides the longest randomized evidence to date supporting early surgical AVR in asymptomatic patients with very severe AS. In this multicenter trial, 145 patients with an aortic valve area ≤0.75 cm² and either a peak jet velocity ≥4.5 m/s or mean gradient ≥50 mm Hg were randomized to early surgery (n=73) or guideline-directed conservative care (n=72). The original results, published in New England Journal of Medicine in 2020, showed that early surgery markedly reduced cardiovascular death over a median follow-up of 6.2 years (1% vs 15%; HR 0.09; 95% CI, 0.01–0.67; p=0.003) and all-cause mortality (7% vs 21%; HR 0.33; 95% CI, 0.12–0.90). In the conservative cohort, sudden cardiac death occurred in 14% of patients by eight years, whereas 95% of surgical patients underwent AVR within two months of randomization, and none experienced operative mortality. The initial results showed that among asymptomatic patients with very severe aortic stenosis, the incidence of the composite of operative mortality or death from cardiovascular causes during the follow-up period was significantly lower among those who underwent early aortic-valve replacement surgery than among those who received conservative care
At the final 10-year follow-up, presented at the 2025 American Heart Association Scientific Sessions, early AVR continued to demonstrate durable benefit. The composite primary endpoint of operative or cardiovascular death occurred in 2 patients (2.7%) in the early-surgery group versus 17 patients (23.6%) in the conservative group (HR 0.10; 95% CI, 0.02–0.43; p=0.002). Death from any cause was also significantly lower with early surgery (15.1% vs 31.9%; HR 0.42; 95% CI, 0.21–0.86; p=0.018), as was hospitalization for heart failure (0.3% vs 19.4%; p=0.015). There were no valve-related operative deaths, and rates of thromboembolic events and repeat AVR were similar. Survival curves separated early and remained widely divergent beyond a decade, confirming the long-term safety and efficacy of early surgical intervention.
Importantly, Dr. Duk Hyun Kang concluded that while RECOVERY provides compelling evidence favoring early surgical AVR in carefully selected asymptomatic patients with very severe AS, these findings are not directly generalizable to transcatheter aortic valve replacement. The trial exclusively enrolled low-surgical-risk patients treated at high-volume surgical centers, and outcomes reflect the procedural safety of modern open AVR. Nonetheless, the extended follow-up of RECOVERY helps establish early surgical AVR as a safe, effective, and enduringly beneficial strategy for asymptomatic severe AS.