Postoperative Atrial Fibrillation/Flutter After TAVR or SAVR

Quick Takes

  • Postoperative atrial fibrillation or flutter (POAF) occurs in 12.3% of patients who undergo surgical or transcatheter valve replacement for severe aortic stenosis, with significantly higher incidence in the surgical group, both early and late.
  • Patients who experience late POAF or any POAF after treatment are at significantly higher risk for a composite endpoint of all-cause mortality, stroke, or rehospitalization at 2 years, regardless of treatment modality.

Study Questions:

What is the incidence and impact of postoperative atrial fibrillation or flutter (POAF) after transcatheter (TAVR) and surgical aortic valve replacement (SAVR)?

Methods:

This is an analysis from the PARTNER 3 trial, a multicenter, prospective, randomized trial examining SAVR versus TAVR with a balloon-expandable valve in patients with severe aortic stenosis at low surgical risk for mortality from SAVR. Patients who experienced POAF at any time following the index procedure and up to 1 year later were grouped into: 1) early, 2) late, and 3) any POAF. Those with pre-existing AF and those who did not undergo AVR were excluded. The primary endpoint was a composite of all-cause mortality, stroke, or rehospitalization at 2 years. Secondary endpoints were rehospitalization for procedure- or device-related adverse events or heart failure, all-cause death, cardiovascular death, stroke, and major bleeding.

Analysis was performed in the as-treated population. Logistic regression was used to predict early, late, and any POAF with a model adjusting for age, sex, history of diabetes, history of hypertension, history of congestive heart failure, history of stroke or transient ischemic attack, body mass index, baseline hemoglobin, creatinine clearance, left ventricular ejection fraction, left atrial volume (LAV), and treatment modality. Multivariable Cox proportional hazards regression analysis was used to examine the association between POAF and adverse clinical outcomes.

Results:

Median follow-up was 2.1 years (interquartile range [IQR], 2.01-2.45 years). Of 781 patients included in the analysis, 366 underwent SAVR and 415 TAVR. Early POAF occurred in 19.5% (n = 152) and occurred significantly more frequently after SAVR than TAVR (36.6% vs. 4.3%, p < 0.0001), although by the time of hospital discharge, early POAF had resolved in 31.9% of those in the SAVR group. After discharge, late POAF occurred in 7.0% (n = 55) and again, significantly more frequently following SAVR (10.4% vs. 3.8%, p < 0.0001). Within 1 year of the index procedure, any POAF was detected in 12.3% (n = 196), with 44.5% occurring after SAVR and 8.0% after TAVR (p < 0.0001).

LAV and SAVR were independently associated with increased risk for early and any POAF. After adjustment, early POAF was not associated with increased 2-year risk for the composite outcome (hazard ratio [HR], 1.10; 95% confidence interval [CI], 0.64-1.91; p = 0.72), but late (HR, 8.90; 95% CI, 5.03-15.74, p < 0.0001) and any (HR, 2.39; 95% CI, 1.45-3.94; p = 0.0006) POAF were. Early, late, or any POAF was not significantly associated with risk for major bleeding. There was no interaction between the treatment and varying impact of POAF.

Conclusions:

POAF occurs more frequently after SAVR than TAVR, both early and late. LAV and treatment with SAVR were significant predictors of any POAF. Late and any POAF were associated with an increased risk for a composite outcome of all-cause mortality, stroke, or rehospitalization at 2 years.

Perspective:

Despite various antiarrhythmia protocols to prevent POAF after cardiac surgery, the incidence remains high and occurs more frequently after SAVR compared to TAVR. Anticoagulation protocols vary for early POAF that occurs after cardiac surgery and is brief and/or self-limited. Further study is needed to understand how POAF, especially when occurring late after SAVR and TAVR, can be mitigated and treated to decrease risk of adverse outcomes.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Structural Heart Disease

Keywords: Anticoagulants, Aortic Valve Stenosis, Arrhythmias, Cardiac, Atrial Fibrillation, Cardiac Surgical Procedures, Heart Failure, Heart Valve Diseases, Heart Valve Prosthesis, Hemorrhage, Patient Discharge, Secondary Prevention, Stroke, Transcatheter Aortic Valve Replacement


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