Background <p>The treatment of patients with asymptomatic severe aortic stenosis (SAS) with left ventricular ejection fraction (LVEF) retention remains controversial.</p> Objective <p>The study aimed to evaluate the safety and efficacy of these three treatment modalities and to provide evidence for their clinical application and promotion.</p> Methods <p>This multicenter retrospective study included asymptomatic patients with SAS who accepted treatment [defined as normal left ventricular function, aortic valve area ≤ 1.0 cm², peak velocity (V_max) ≥ 4.0&#xa0;m/s or mean pressure gradient ≥ 40&#xa0;mmHg]. Patients were divided into the transcatheter aortic valve replacement (TAVR) group, the surgical aortic valve replacement (SAVR) group, and the conservative treatment group. The primary end point was all-cause mortality during the follow-up period.</p> Results <p>During follow-up of 66.5 (interquartile range: 63.1–69.2) months, the incidence of the primary end point was lower in the TAVR group than in the conservative treatment group (33.3% vs. 46.4%, <i>P</i> = 0.023), and the incidence of major adverse cardiovascular events was reduced in the SAVR group (12.8% vs. 22.3%, <i>P</i> = 0.047). The incidences of the primary end point (37.3% vs. 60.4%, <i>P</i> &lt; 0.001) and stroke (19.0% vs. 40.7%, <i>P</i> &lt; 0.001) were significantly lower in patients who converted to aortic valve replacement (AVR) compared with those who did not convert to AVR.</p> Conclusions <p>Early AVR improved both primary and secondary end points compared with patients having conservative treatments. Conversion to AVR during conservative treatment was found to be more likely to bring net clinical benefits for such patients.</p> <p><i>Trial registration</i>: ClinicalTrials.gov Protocol Registration System NCT02917980.</p>