Atrial Fibrillation in Severe Aortic Stenosis Post-TAVR
What is the impact of new-onset atrial fibrillation (NOAF) in patients undergoing transcatheter aortic valve replacement (TAVR)?
Consecutive patients (n = 2,706) with severe aortic stenosis who underwent TAVR at multiple European centers were followed for development of NOAF (occurring within 30 days of the procedure) in this analysis from the SOURCE XT prospective registry. The approach was transfemoral in 1,685 (63%), and transapical in 894 patients (33%).
Among 1,925 patients in whom complete baseline and follow-up heart rhythm data were available, pre-existing AF was present in 685 (36%). For the purpose of comparison, patients were divided into three groups: those who remained in sinus rhythm (n = 1,102) up to 30 days post-procedure, with pre-existing AF (n = 685), and those who developed NOAF (n = 138; 7.2%). Patients with NOAF were more likely to have undergone the procedure via a transapical approach, requiring general anesthesia, had severe renal dysfunction, and a prior pacemaker/defibrillator. Patients with pre-existing AF and NOAF were more likely to experience worse outcomes (all-cause mortality and bleeding) as compared to those who remained in sinus rhythm. Patients with NOAF were more likely to experience stroke at 2 years as compared to those in sinus rhythm. Multivariate analysis revealed that nontransfemoral approach (hazard ratio [HR], 3), advanced heart failure symptoms (HR, 1.9), post-dilatation of the prosthesis (HR, 1.6), and age (HR, 1.1) were independently associated with NOAF.
The authors concluded that new-onset AF occurs in about 7% of patients undergoing TAVR and is associated with worse outcomes.
Patients undergoing TAVR are afflicted with conditions that are also associated with AF, including advancing age, hypertension, heart failure, and of course, valvular disease. It should thus not be surprising that some patients develop AF, albeit, at a much lower rate than those undergoing valve replacement via sternotomy and cardiopulmonary bypass. As the transapical approach (which involves pericardial manipulation) is becoming less common (33% in this study), the incidence of NOAF is likely to decrease as well.
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