Courtesy of Dr. Carlos Fava.

Transcatheter aortic valve replacement (TAVR) has emerged as an important treatment alternative for intermediate- and high-risk patients. In that sense, the presence of atrial fibrillation (AF) before TAVR is high and it has been associated with worse outcomes and higher mortality. However, there is not much evidence available regarding new-onset atrial fibrillation after TAVR. We ignore its implications and the best course of treatment (whether pharmacological or invasive).

This study analyzed 13,356 patients who underwent TAVR. Among them, 1138 (8.4%) developed new AF (NAF) after percutaneous valve implantation.

The characteristics of both groups were similar, although patients with NAF presented the following particular features: patients were older (with a higher percentage of female subjects) and had higher rates of chronic obstructive pulmonary disease (COPD), higher Society of Thoracic Surgery predicted risk of mortality score (6.5 vs. 6.0; p < 0.01), and higher rates of use of transapical access. Furthermore, most were extreme- or high-risk patients.

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The hospital stay for this group was longer (9 days vs. 5 days; p =< 0.01).

The factors related with the development of NAF were ejection fraction, age, COPD, and non-transfemoral access (4.4% transfemoral access vs. 16.5% non-transfemoral access; p < 0.01).

As regards in-hospital indicators, these patients had higher rates of mortality (7.8% vs. 3.4%; p < 0.01), stroke (4.7% vs. 2.0%; p < 0.01), and major bleeding (10.6% vs. 6.1%; p < 0.01). There were no differences in all other events.

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Despite having a CHA2DS2-VASc score of 5, less than 30% of patients received anticoagulation after discharge. About half the patients received anti-arrhythmia medication and there was a trend towards higher rates of beta-blocker prescription.

At 1 year, there were higher rates of mortality (33.8% vs. 20.7%; p < 0.01), stroke (7.5% vs. 6.3%; p < 0.01), major bleeding (30.1% vs. 35.7%; p < 0.01), and readmission due to heart failure (14.8% vs. 10.5%; p < 0.01). Mortality was similar among patients who received anticoagulation after discharge.

Conclusion

NAF after TAVR occurred in 8.4% of patients (4.4% with transfemoral access vs. 16.5%); less than a third received anticoagulation after discharge and it was associated with increased risk of in-hospital death and stroke at 1 year. Given the clinical significance of developing NAF after TAVR, additional studies are necessary to delineate an optimal treatment strategy for this high-risk population.

Editorial Comment

New-onset atrial fibrillation after TAVR is not a minor detail and it must be taken into account at the time of discharge, since it indicates that the patient in question has more comorbidities and, at the same time, that this arrhythmia must be treated and controlled in the future.

While anticoagulation is associated with higher rates of non-fatal bleeding, its lack of indication was associated with higher rates of stroke and death.

This registry showed that anticoagulant agents neutralize mortality at 1 year, although, in this case, only one study group received this medication. We should be more careful with this population, carrying out more intensive follow-up procedures to try and improve their progress.

Courtesy of Dr. Carlos Fava.

Original title: Incidence, Management, and Associated Clinical Outcomes of New-Onset Atrial Fibrillation Following Transcatheter Aortic Valve Replacement: An Analysis from the STS/ACC TVT Registry.

Reference: Amit N. Vora et al. J Am Coll Cardiol Intv 2018;11:1746-56.

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