Incidence, Predictors, Management, and Clinical Significance of New-Onset Atrial Fibrillation After Transcatheter Aortic Valve Implantation

Background Post-operative atrial fibrillation (POAF) is the most common complication after cardiac surgery. Recent studies had shown this phenomenon is no longer considered transitory and is associated with higher risk of thromboembolic events or death. The aim of this study was to systematically review and analyze previous studies comparing oral anticoagulation therapy with no anticoagulation, regarding these long-term outcomes. Methods PubMed/MEDLINE, EMBASE, Web of Science and Cochrane Database were systematically searched to identify the studies comparing the risk of stroke, or thromboembolic events or mortality of POAF patients who received anticoagulation compared with those who were not anticoagulated. Incidence of stroke, thromboembolic events and all-cause mortality were evaluated up to 10 years after surgery. Time-to-event outcomes were collected through hazard ratio (HR) along with their variance and the early endpoints using frequencies or odds ratio (OR). Random effect models were used to compute statistical combined measures and 95% confidence intervals (CI). Heterogeneity was evaluated through Q statistic-related measures of variance (Tau2, I2, Chi-squared test). Results Eight observational cohort studies were selected, including 15,335 patients (3492 on Oral Anticoagulants (OAC) vs 11,429 without OAC) that met the inclusion criteria for qualitative synthesis. Patients had a wide gender distribution (38.6–82.3%), each study with a mean age above 65 years (67.5–85). Vitamin K antagonists were commonly prescribed anticoagulants (74.3–100%). OAC was associated with a protective impact on all-cause mortality at a mean of 5.0 years of follow-up (HR is 0.85 [0.72–1.01]; p = 0.07; I2 = 48%). Thromboembolic events did not differ between the two treatment arms (HR 0.68 [0.40–1.15], p = 0.15). Conclusion Current literature suggests a possibly protective impact of OAC therapy for all-cause mortality in patients with new-onset atrial fibrillation after cardiac surgery. However, it does not appear to impact thromboembolism rate.

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“…All papers were observational and based on a prospective cohort (Table 1). The [23,26] and valve repair/replacement [24,25,27].…”

Section: Resultsmentioning

confidence: 99%

Impact of oral anticoagulation therapy on postoperative atrial fibrillation outcomes: a systematic review and meta-analysis

et al. 2021

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“…This meta-analysis showed that NOAF was associated with an increased risk of 30-day mortality, AKI, early bleeding, stroke, and extended LOS in patients with TAVI/TAVR [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] [ Fig. 1 ].…”

Section: Discussionmentioning

confidence: 99%

Impact of new-onset versus pre-existing atrial fibrillation on outcomes after transcatheter aortic valve replacement/implantation

Nso

Emmanuel

Nassar

et al. 2022

IJC Heart & Vasculature

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“…Pre-existing AF is present in 30-40% of patients undergoing TAVR [6,7,[11][12][13][14][15][16]37,38] (Figure 3). While new onset of AF is less frequent in patients with severe aortic stenosis undergoing TAVR compared to SAVR [40,41], it is a common complication after TAVR, with a prevalence reaching 16% at 30 days, 21% at 1 year and 25% at 5 years (Figure 3) [14,42], and is associated with a higher rate of stroke and mortality within the first year [37,[43][44][45][46][47]. Despite the known risk of ischemic and embolic events with AF, there is still an important international variability in discharged medication patterns in patients with a history of AF undergoing TAVR [44], with 40% of patients discharged without OAC therapy in the recent large registry from Sherwood et al [48].…”

Section: Atrial Fibrillation and The Risk Of Cerebrovascular Eventsmentioning

confidence: 99%

Antithrombotic Therapy Following Transcatheter Aortic Valve Replacement

Guedeney

Collet

2022

JCM

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Due to a large technical improvement in the past decade, transcatheter aortic valve replacement (TAVR) has expanded to lower-surgical-risk patients with symptomatic and severe aortic stenosis. While mortality rates related to TAVR are decreasing, the prognosis of patients is still impacted by ischemic and bleeding complications, and defining the optimal antithrombotic regimen remains a priority. Recent randomized control trials reported lower bleeding rates with an equivalent risk in ischemic outcomes with single antiplatelet therapy (SAPT) when compared to dual antiplatelet therapy (DAPT) in patients without an underlying indication for anticoagulation. In patients requiring lifelong oral anticoagulation (OAC), the association of OAC plus antiplatelet therapy leads to a higher risk of bleeding events with no advantages on mortality or ischemic outcomes. Considering these data, guidelines have recently been updated and now recommend SAPT and OAC alone for TAVR patients without and with a long-term indication for anticoagulation. Whether a direct oral anticoagulant or vitamin K antagonist provides better outcomes in patients in need of anticoagulation remains uncertain, as recent trials showed a similar impact on ischemic and bleeding outcomes with apixaban but higher gastrointestinal bleeding with edoxaban. This review aims to summarize the most recently published data in the field, as well as describe unresolved issues.

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Incidence, Predictors, Management, and Clinical Significance of New-Onset Atrial Fibrillation After Transcatheter Aortic Valve Implantation

Cited by 23 publications

References 19 publications

Impact of oral anticoagulation therapy on postoperative atrial fibrillation outcomes: a systematic review and meta-analysis

Impact of oral anticoagulation therapy on postoperative atrial fibrillation outcomes: a systematic review and meta-analysis

Impact of new-onset versus pre-existing atrial fibrillation on outcomes after transcatheter aortic valve replacement/implantation

Antithrombotic Therapy Following Transcatheter Aortic Valve Replacement

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