Patients with Atrial Fibrillation Benefit from SAVR with Surgical Ablation Compared to TAVR Alone

Abstract

Introduction:In patients with preoperative atrial fibrillation (AF) undergoing aortic valve replacement, the addition of surgical ablation to surgical aortic valve replacement (SAVR-SA) is efficacious and a Class I guideline. We hypothesized that this subgroup may benefit from SAVR-SA compared to transcatheter aortic valve replacement (TAVR) alone. Methods: Medicare beneficiaries with persistent non-valvular AF who underwent SAVR-SA or TAVR alone between 2012 and 2018 were included. Patients with high-risk surgical comorbidities were excluded. Groups were matched using inverse probability weighting. The primary outcome was all-cause mortality. Secondary outcomes were stroke, transient ischemic attack, permanent pacemaker implantation, bleeding, rehospitalization for atrial arrhythmias, and rehospitalization for heart failure. Kaplan-Meier estimates and Cox proportional-hazards regression were used to compare outcomes. Outcomes were adjusted for variables with a standardized mean difference greater than 0.1. Results: Of 439,492 patients who underwent aortic valve replacement, 2591 underwent SAVR-SA and 1494 underwent TAVR alone. Weighting resulted in adequately matched groups. Compared to TAVR alone, SAVR-SA was associated with a significant reduction in allcause mortality (HR 0.65, 95% CI 0.53-0.79), permanent pacemaker implantation (HR 0.62, 95% CI 0.44-0.87), bleeding (HR 0.63, 95% CI 0.39-1.00), and rehospitalization for heart failure (HR 0.49 (0.36-0.65). There was no difference in the incidence of stroke (HR 1.07, 95% CI 0.74-1.54), transient ischemic attack (HR 1.05, 95% CI 0.75-1.47), or rehospitalization for atrial arrhythmia. Conclusion: Select patients with persistent non-valvular AF may benefit from SAVR-SA compared to TAVR alone.

Surgical Treatment of Patients with Aortic Valve Disease in Association with Atrial Fibrillation

“…Combined open procedures show significantly better long-term outcomes than isolated transcatheter aortic valve implantation in elderly patients with low surgical risk and persistent atrial fibrillation. An analysis conducted by William L Patrick et al demonstrates reduced mortality, pacemaker implantation rates, and hospitalizations due to decompensated heart failure in the long-term period for patients who underwent arrhythmia correction and prosthetic valve replacement under cardiopulmonary bypass, compared to the transcatheter aortic valve implantation group (TAVI) group where ablation was not performed [44].…”

The Evolving Role of Surgical Aortic Valve Replacement in the Era of Transcatheter Valvular Procedures

“…tion ablation with a MAZE procedure. Recent data have shown that patients with severe AS and persistent AF who undergo SAVR or TAVR without AF ablation have a higher risk of long-term mortality [91].…”

“…Additionally, patients with chronic atrial fibrillation may also benefit from surgery by undergoing concomitant atrial fibrillation ablation with a MAZE procedure. Recent data have shown that patients with severe AS and persistent AF who undergo SAVR or TAVR without AF ablation have a higher risk of long-term mortality [ 91 ].…”