Predictors and risk-adjusted outcomes of new-onset postoperative atrial fibrillation in repeat surgical and valve-in-valve transcatheter aortic valve replacement

Abstract

Aim: New-onset postoperative atrial fibrillation/flutter (POAF/AFL) complications have not been well studied for repeat aortic valve replacements (r-AVR); this study identified risk factors predisposing to POAF/AFL and POAF/AFL’s effect upon risk-adjusted outcomes. Methods: Using New York State’s Statewide Planning and Research Cooperative System records (2005-2018), multivariable forward selection models identified risks predictive of POAF/AFL. To identify POAF/AFL’s impact upon risk-adjusted mortality/morbidity (MM) and 30-day readmission (READMIT), forward selection logistic regression models applied Firth bias correction to address data sparsity. Results: Of the 242 r-AVR patients, 147 underwent repeat surgical aortic valve replacements (r-SAVR) and 95 underwent valve-in-valve transcatheter aortic valve replacements (ViV-TAVR); 39.46% of r-SAVR and 43.16% of ViV-TAVR patients had POAF/AFL. R-SAVR patients with POAF/AFL were older (69.7 ± 11.1 vs. 56.7 ± 13.2 years, P < 0.01) compared to R-SAVR patients without POAF/AFL. Multivariable models identified an enhanced POAF/AFL risk for elderly (OR: 1.05, 95%CI: 1.03-1.07, P < 0.01) and cerebral vascular disease (OR: 2.18, 95%CI: 1.05-4.55, P = 0.04) patients. Bivariately, POAF/AFL was associated with READMIT, but not MM. Correspondingly, multivariable models found POAF/AFL increased READMIT (OR: 3.12, 95%CI: 1.46-6.65, P < 0.01), but not MM. However, black race (OR: 4.97, 95%CI: 1.61-15.37, P < 0.01) and Elixhauser score (OR: 1.05, 95%CI: 1.02-1.08, P < 0.01) increased risk for MM. Conclusion: More common in older and cerebrovascular disease patients, 41% of r-AVR patients with POAF/AFL had increased READMIT risk; thus, future investigations should focus on improving POAF/AF r-AVR patients’ post-discharge continuity of care.

Editorial review: guidance for future atrial fibrillation research

“…The potential for a causal relationship between POAF and stroke was assessed by Rademacher et al [15] . This systematic review ascertained the published evidence related to using anticoagulation for POAF patients to prevent adverse outcomes (e.g., stroke).…”

“…Challenges were discussed as to the optimal management of a POAF patient's anticoagulation medication regimen as part of their overall cardiovascular risk management plan. Therefore, to optimize future patient outcomes, future POAF research appears warranted to directly address this hypothesis by taking a more patient-focused (rather than a treatment-focused or medication-focused) approach to identifying a potential stroke impact [15] . Although many publications on first-time aortic valve replacement and repair procedures (AVR) and the association with POAF exist, a paucity of knowledge persists regarding the POAF impact upon repeat aortic valve replacement (r-AVR) procedural patients' outcomes and resource utilization; additionally, the risk factors associated with r-AVR patients' new-onset POAF complications have not been well studied.…”