Temporal Trends and Outcomes of Percutaneous and Surgical Aortic Valve Replacement in Patients With Atrial Fibrillation

Abstract

Objectives: The aim of this study was to evaluate the temporal trends of transcatheter aortic valve replacement (TAVR) in severe aortic stenosis (AS) patients with atrial fibrillation (AF) and to compare the in-hospital outcomes between TAVR and surgical aortic valve replacement (SAVR) in patients with AF.Background: Data comparing TAVR to SAVR in severe AS patients with AF are lacking.Methods: National inpatient sample database in the United States from 2012 to 2016 were queried to identify hospitalizations for severe aortic stenosis patients with AF who underwent isolated aortic valve replacement. A propensity score-matched analysis was used to compare in-hospital outcomes for TAVR vs. SAVR for AS patients with AF.Results: The analysis included 278,455 hospitalizations, of which 124,910 (44.9%) were comorbid with AF. Before matching, TAVR had higher in-hospital mortality than SAVR (3.1 vs. 2.2%, p < 0.001); however, there was a declining trend during the study period (Ptrend < 0.001). After matching, TAVR and SAVR had similar in-hospital mortality (2.9 vs. 2.9%, p < 0.001) and stroke. TAVR was associated with lower rates of acute kidney injury, new dialysis, cardiac complications, acquired pneumonia, sepsis, mechanical ventilation, tracheostomy, non-routine discharge, and shorter length of stay; however, TAVR was associated with more pacemaker implantation and higher cost. Of the patients receiving TAVR, the presence of AF was associated with an increased rate of complications and increased medical resource usage compared to those without AF.Conclusions: In-hospital mortality and stroke for TAVR and SAVR in AF, AS are similar; however, the in-hospital mortality in TAVR AF is declining and associated with more favorable in-hospital outcomes.

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

“…The exact predictors of pre-existing atrial fibrillation in SAVR patients are unknown. However, some predictors of pre-existing atrial fibrillation in TAVR patients include the presence of moderate to severe mitral regurgitation, moderate to severe tricuspid regurgitation, and pulmonary hypertension [5] . Other predictors of TAVR with atrial fibrillation include older age, female gender, and comorbidities such as diabetes, chronic lung disease, congestive heart failure, chronic renal disease, anemia, arthritis, hypothyroidism, and peripheral vascular disease [6] .…”

“…Pre-existing atrial fibrillation has been reported in 15.7%-48.9% of patients undergoing TAVR [Table 2]. Furthermore, Tarantini et al [5] reported that pre-existing atrial fibrillation has a significantly higher prevalence in TAVR patients treated using the transapical approach than those treated using the transfemoral approach (41.8% vs. 32.7%, P < 0.01). The higher rates of preoperative atrial fibrillation in TAVR compared to SAVR can be attributed to more comorbidities and a worse clinical profile among TAVR patients [21] .…”

“…Multivariate adjusted Cox proportional hazard analysis conducted by Yankelson et al [16] found that previous AF (OR = 2.2; 95%CI: 1.3-3.8) was the most significant predictor of mortality throughout the follow-up period after the TAVR procedure. Several other studies have shown baseline AF to be significantly associated with higher 1-year mortality or predicting 1-year mortality [5,18,19,20,25] .…”

Trend and Impact of Concomitant CABG and Multiple-Valve Procedure on In-hospital Outcomes of SAVR Patients

“…Many large inpatient cohorts, such as NIS, are subject to coding and documentation errors. Additionally, retrospective observational analysis was liable to selection bias; however, the database has been validated internally and externally (12)(13)(14). This national dataset analysis shows the latest real-world data of combined procedure practice patterns for SAVR and their impact on in-hospital outcomes.…”