Does Post-AVR Afib Risk Merit Months of Vigilance?

The timing of a common postoperative complication was of high prognostic importance for people at low surgical risk undergoing aortic valve replacement, according to an analysis of the PARTNER 3 trial.

In line with common thinking, in-hospital atrial fibrillation (Afib) or atrial flutter appeared to be a bystander phenomenon: such early Afib was not an independent predictor of Afib episodes following discharge (OR 1.04, 95% CI 0.52-2.08), nor did it predict the composite outcome of death, stroke, or rehospitalization over 2 years (HR 1.10, 95% CI 0.64-1.92).

In contrast, post-discharge Afib was associated with an increased adjusted risk for the composite outcome (adjusted HR 8.90, 95% CI 5.02-15.74), with more than 11-fold excesses in stroke and rehospitalization in particular.

This was observed regardless of whether the patient had received transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR), according to Ioanna Kosmidou, MD, PhD, of Columbia University Irving Medical Center in New York City, and colleagues, writing in JACC: Cardiovascular Interventions.

Study results “imply that vigilant cardiac rhythm monitoring and frequent clinical evaluation is crucial for several months following the index procedure,” the authors concluded.

“Furthermore, as complex structural interventions are more frequently tested in low-surgical risk populations, recognition and appropriate management of readily identifiable factors such as POAF [postoperative Afib], which may adversely affect an overall favorable clinical outlook, are ever more crucial and should be at the forefront of pre- and postprocedural strategy,” they said.

In PARTNER 3, early postoperative Afib occurred in 4.3% of patients after TAVR and 36.6% after SAVR (P<0.0001) -- similar to what has been observed in higher-risk cohorts.

Between discharge and 1 year, late Afib was detected in 3.9% versus 10.7%, respectively (P<0.0001). Nearly half of late Afib events were identified within 30 days from the index procedure.

“Whether late POAF is a direct risk factor or a marker of a severe or chronic atherothrombotic process, in contrast to early POAF, which may, in isolation, be a self-limiting phenomenon, cannot be fully discerned from the present study,” Kosmidou’s group acknowledged.

In an accompanying editorial, Marvin Eng, MD, and two colleagues of Banner University Medical Center in Phoenix, agreed that “focused attention to patients at high risk for Afib should be implemented.”

“All in all, early and late POAF will continue to plague patients, especially those undergoing treatment for valvular heart disease. Winning the war against POAF requires vigilance in detection and treatment. Certainly, the present paper serves as a call to action for improving the innovation and quality of Afib prophylaxis for procedures, particularly cardiac surgery,” Eng’s group wrote.

PARTNER 3 participants included for the current study were 781 low-risk patients with severe aortic stenosis undergoing TAVR with the Sapien 3 valve (n=415) or surgery (n=366).

Approximately half of patients with early postoperative Afib were discharged on some type of anticoagulant. The authors did not report in detail the type of anticoagulation and quality of therapy received, Eng’s team noted.

“Without the details of prophylactic measures, we can only speculate that POAF prevention may not have been optimal given the high rate of early POAF,” the editorialists said.

Kosmidou and colleagues also cautioned that their present analysis had not been prespecified, and that Afib was recorded only if clinically manifest or caught on ECG. Moreover, adverse event rates were low, suggesting a need for larger studies to confirm the findings.

The main finding of PARTNER 3 was that TAVR proved superior to SAVR in terms of 1-year outcomes for patients at low surgical risk. By 2 years, however, the TAVR arm had disproportionately more deaths and strokes such that any remaining difference between groups appeared to be driven by rehospitalizations alone.

1. 
   

Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow

Disclosures

PARTNER 3 was funded by Edwards Lifesciences.

Kosmidou has received institutional research support from Amgen and is a consultant for Sanofi.

Eng is a clinical proctor for Edwards Lifesciences and Medtronic, and is a consultant for AngioDynamics.

Read More