Door-to-Valve Intervention Time and Clinical Outcomes in Acute Decompensated Severe Aortic Stenosis: Systematic Review and Meta-Analysis
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Background
Acute decompensated aortic stenosis (ADAS) carries high mortality, but the optimal timing of valve intervention is unknown.
Objective
To assess the association between time to valve intervention (transcatheter aortic valve replacement [TAVR] or balloon aortic valvuloplasty [BAV]) and clinical outcomes in ADAS.
Methods
Embase, Ovid MEDLINE and CENTRAL were searched to May 15, 2026. Hazard ratios (HRs) for delayed versus earlier intervention were pooled using random-effects models with modified Hartung-Knapp inference. Unadjusted short-term mortality risk ratios (RRs) were pooled using the Mantel-Haenszel method.
Results
Eight observational cohort studies (n=6,044) met inclusion criteria: six TAVR (n= 5,986) and two BAV (n=58) studies. Patients were approximately 79 years old, and 63% were male. Early-intervention thresholds ranged from <24-48 hours (BAV) to ≤22 days (TAVR) from admission. Delayed intervention was not significantly associated with long-term all-cause mortality (HR 1.52, 95% CI 0.46-5.00; p=0.269; I 2 =58.2%) or mortality per five-day delay (HR 1.09, 95% CI 0.34-3.43; p=0.530; I 2 =86.7%). Crude short-term mortality was higher with delayed intervention (RR 4.96, 95% CI 1.17-20.92; p=0.029; I 2 =0.0%), although this association was not robust to sensitivity analyses. Most studies were at serious risk of bias, with substantial heterogeneity in clinical severity, intervention timing, and treatment modality.
Conclusion
Point estimates favour earlier intervention, but current observational data do not establish a mortality benefit for an optimal door-to-valve interval, and existing study designs are biased against early treatment. Prospective and randomized-controlled trials on optimal valve intervention timing following ADAS are needed.
