Pre-operative and post-operative atrial fibrillation in patients undergoing SAVR/TAVR

Abstract

Atrial fibrillation (AF) is a common preoperative comorbidity and post-operative complication associated with cardiac surgery and is recognized as a significant predictor of adverse clinical outcomes. This review aims to highlight the current literature regarding the incidence, risk factors, and outcomes of atrial fibrillation in patients undergoing surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) procedures. A literature search of relevant articles was conducted via PubMed, Medline, and EMBASE. Pre-existing AF is seen in 6.3%-35.2% of SAVR patients and 15.7%-48.9% of TAVR patients and is associated with increased risk of mortality (OR = 2.2) and stroke (OR = 5.9). Postoperative AF (POAF) is more common after SAVR and in patients with hemodynamic instability. The rates for POAF range from 11.1%-84% following SAVR and range from 3.0%-55.6% following TAVR. In-hospital mortality (7.8% vs. 3.4%; P < 0.01) and stroke (4.7% vs. 2.0%; P < 0.01) are higher in the POAF group. POAF can be prevented via prophylactic antiarrhythmic medications and atrial pacing. Therapeutic anticoagulation is recommended as it reduces the risk of thrombotic complications following SAVR and TAVR procedures in the setting of POAF. Compared to those not on anticoagulant therapies, patients on anticoagulation have decreased rates of stroke (1.7% vs. 5.5%) and fewer 30-day thrombotic complications (3% vs. 40%). These preventive measures are essential as POAF is associated with more thromboembolic events, longer hospital stays, and higher overall morbidity and mortality rates.

Editorial review: guidance for future atrial fibrillation research

“…Although CABG patients' POAF rates have been reportedly high [5,11] , Dokko's systematic review reported that the highest cardiac surgical post-procedural POAF rates have been found for mitral valve replacement or repair (MVR) procedures; moreover, the authors reported that very innovative technological advances have taken place [12] . For all MVR patients with preoperative AF and POAF, medical therapy should be evaluated as a treatment to avoid POAF.…”

“…Fundamentally, it is unclear if catheter-based ablation should be recommended during the same hospitalization (i.e., before, during, or after the MVR procedure) or within 30 days of discharge. As a matter of discussion, the role of a prophylactic occlusion of the LA appendage (LAAO), which has been evaluated (LAAOS III trial) during surgical MVR procedures to avoid post-MVR thromboembolic events (e.g., stroke), should find its way into treatment algorithms [12] .…”