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Systematic Review of New-Onset Atrial Fibrillation Post-TAVR
Quick Takes
- New-onset AF after TAVR is common and occurs in approximately 1 in 10 TAVR patients.
- New-onset AF is associated with several adverse outcomes, including mortality, stroke, major bleeding, permanent pacemaker implantation, and longer in-hospital stay.
- Additional studies are needed to determine the optimal monitoring time frame for AF after TAVR, strategies to reduce AF, and the role of anticoagulation to reduce stroke.
Study Questions:
What is the occurrence of new-onset atrial fibrillation (AF) after transcatheter aortic valve replacement (TAVR) and the outcomes and predictors associated with this complication?
Methods:
The investigators searched Medline, EMBASE, and the Cochrane database from 2016–2020 for articles that reported new-onset AF after TAVR and performed a systematic review evaluating the occurrence of new-onset AF after TAVR. They extracted data for studies published prior to 2016 from a previous systematic review. Outcomes included hospital length of stay, stroke (overall and occurring before and after 30 days), death in hospital or within 30 days, major or life-threatening bleeding, need for permanent pacemaker (PPM) implantation, and readmission to the hospital within 30 days. The authors pooled data using a random-effects model.
Results:
The authors identified 179 studies with 241,712 total participants (55,271 participants with pre-existing AF were excluded) that reported new-onset AF from 2008–2020. The pooled occurrence of new-onset AF after TAVR was 9.9% (95% confidence interval [CI], 8.1-12%). New-onset AF after TAVR was associated with longer index hospitalization (mean difference, 2.66 days; 95% CI, 1.05-4.27), higher risks of stroke in the first 30 days (relative risk [RR], 1.7; 95% CI, 1.1-2.5), 30-day mortality (RR, 1.76; 95% CI, 1.12-2.76), major or life-threatening bleeding (RR, 1.60; 95% CI, 1.39-1.84), and PPM implantation (RR, 1.12; 95% CI, 1.05-1.18). Risk factors for the development of new-onset AF after TAVR included higher Society of Thoracic Surgeons (STS) score, transapical access, pulmonary hypertension, chronic kidney disease, peripheral vascular disease, and severe mitral regurgitation, suggesting that risk for new-onset AF is highest in more comorbid TAVR patients.
Conclusions:
The authors concluded that new-onset AF is common after TAVR.
Perspective:
This systematic review and meta-analysis reports that new-onset AF occurs in approximately 1 in 10 TAVR patients. Furthermore, new-onset AF is associated with several adverse outcomes, including mortality, stroke, major bleeding, PPM implantation and longer in-hospital stay. Risk factors for new-onset AF after TAVR included older age, higher STS score, transapical access route, chronic kidney disease, peripheral vascular disease, severe mitral regurgitation, and pulmonary hypertension, indicating that new-onset AF after TAVR occurs more frequently in patients with comorbidities. It remains unclear whether AF after TAVR is a causal factor or a marker of sicker patients and additional studies are needed to determine the optimal monitoring time frame after TAVR, strategies to reduce AF, and the role of anticoagulation to reduce stroke.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), 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, Pulmonary Hypertension, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Hypertension, Mitral Regurgitation
Keywords: Anticoagulants, Aortic Valve Stenosis, Arrhythmias, Cardiac, Atrial Fibrillation, Cardiac Surgical Procedures, Geriatrics, Heart Valve Diseases, Hemorrhage, Hypertension, Pulmonary, Length of Stay, Mitral Valve Insufficiency, Pacemaker, Artificial, Patient Readmission, Peripheral Vascular Diseases, Renal Insufficiency, Chronic, Risk Factors, Secondary Prevention, Stroke, Transcatheter Aortic Valve Replacement
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