New-onset atrial fibrillation common after aortic-valve replacement

By Will Boggs MD

NEW YORK (Reuters Health) - 4/6/2019

"The frequency with which atrial fibrillation was seen in hospitalizations for aortic-valve procedures and its association with in-hospital stroke and in-hospital mortality were both surprising to us," Dr. Rajat Kalra of the University of Minnesota, in Minneapolis, told Reuters Health by email. "It was also surprising to note that the incidence of atrial fibrillation with TAVI is not insignificant and associated with similar consequences." Previous studies have reported incidences of atrial fibrillation after TAVI and AVR ranging from 8% to 100%, and new-onset AF in this setting has been associated with increased morbidity and mortality.

Dr. Kalra and colleagues used data from more than 171,000 hospitalizations for TAVI or AVR included in the NIS to evaluate the incidence of new-onset AF after TAVI and AVR. The incidence of new-onset AF was 50.4% among TAVI hospitalizations and 50.1% among AVR hospitalizations, they report in JAMA Internal Medicine, online June 3.

New-onset AF was associated with 57% higher odds of in-hospital mortality after TAVI and with 36% higher odds of in-hospital mortality after AVR, both significant increases compared with the absence of new-onset AF.

In both settings, hospitalizations with new-onset AF were associated with significantly longer median length of stay and, after TAVI, new-onset AF was also associated with higher odds of in-hospital stroke.

In a validation cohort of 6,877 index hospitalizations for TAVI and AVR included in the New York state inpatient database, the incidence of new-onset AF was 14.1% (244/1,736) after TAVI and 30.6% (1,573/5,141) after AVR.

"Atrial fibrillation is commonly associated with TAVI and AVR and has important morbidity and mortality implications," Dr. Kalra said. "Clinicians should consider discussing the possibility of atrial fibrillation as a post-procedural complication as part of the shared decision-making process prior to aortic-valve procedures."

"Our findings also reiterate the urgent need to find a balanced approach for peri-procedural anticoagulation for aortic valve procedures," he said. "This is an area that is already rife with debate in modern-day cardiovascular medicine, given the prognostic associations of atrial fibrillation that we (and others) have demonstrated and the emerging data regarding transcatheter aortic-valve thrombosis."

"It is important to note that our study is limited by the inability to capture key details, such as duration of atrial fibrillation, granular differences in patient management before and after the development of atrial fibrillation, the temporal sequence of stroke and atrial fibrillation, and possible coding issues that may lead to prevalent atrial fibrillation to be coded as new-onset atrial fibrillation," Dr. Kalra added.


JAMA Intern Med 2019.

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