The long-term prognosis of asymptomatic moderate-to-severe aortic regurgitation (AR) remains uncertain, with ongoing debate regarding optimal timing of intervention. A systematic review and meta-analysis published in Heart evaluated adverse outcomes during conservative management and examined the association between early aortic valve replacement or repair (AVR) and mortality.

The analysis included cohort studies identified through systematic searches from database inception through July 2025. Random-effects models were used to estimate pooled incidence rates of adverse outcomes, while fixed-effects models evaluated hazard ratios comparing AVR with conservative management. Overall, 27 studies involving 4,720 patients with asymptomatic moderate or severe AR were included.

Findings

• The pooled incidence rate for all-cause mortality was 1.75 per 100 person-years (95% confidence interval [CI] 1.27-2.41).
• New symptom development occurred at a rate of 4.30 per 100 person-years, while AVR occurred at 7.01 per 100 person-years during follow-up.
• Sudden death was relatively uncommon, occurring at 0.29 per 100 person-years.
• Asymptomatic low left ventricular ejection fraction developed infrequently, with an incidence rate of 0.9 per 100 person-years.
• Mortality rates were more than doubled compared with the general population across age groups, including 2.45 per 100 person-years (95% CI 1.90-3.18) in cohorts with a mean age ≥50 years.
• Early AVR was associated with lower mortality compared with conservative management (pooled hazard ratio [HR] 0.33; 95% CI 0.30-0.37).

Asymptomatic moderate-to-severe AR was associated with substantial excess mortality despite relatively infrequent progression to asymptomatic left ventricular dysfunction. Early AVR was associated with lower mortality, although interpretation should remain cautious given study heterogeneity and observational data limitations.