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New-onset AF common in patients undergoing TAVI
Amat-Santos IJ. J Am Coll Cardiol. 2011;doi:10.1016/j.jacc.2011.09.061.
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Approximately one-third of patients undergoing transcatheter aortic valve implantation experienced new-onset atrial fibrillation, which was associated with worse clinical outcomes after the procedure, new data suggest.
Between 2007 and 2011, researchers in Quebec City evaluated 138 patients with no prior history of AF who underwent transcatheter aortic valve implantation (TAVI) with a balloon-expandable valve (Sapien and Sapien XT, Edwards Lifesciences). They prospectively gathered clinical, echocardiographic, procedural and follow-up data for a median of 1 year.
Of all patients examined, 31.9% experienced new-onset AF at a median time of 48 hours after TAVI. Forty percent of episodes occurred during or within 24 hours after the procedure, according to the researchers. A multivariate analysis revealed that larger atrial size (OR=1.21 for each 1 mm/m2 increase; 95% CI, 1.09-1.34) and transapical approach (OR=4.08; 95% CI, 1.35-12.31) were two independent predictors of new-onset AF. The researchers also determined that an atrial size of at least 27 mm/m2 as the cutoff point had the best sensitivity (67%) and specificity (61%) for predicting new-onset AF within 30 days after TAVI.
After 30 days, the rate of stroke/systemic embolism was higher in patients who experienced new-onset AF vs. those who did not experience new-onset AF after TAVI (13.6% vs. 3.2%; OR=4.79; 95% CI, 1.14-20.15). Mortality, however, did not differ between groups (9.1% vs. 6.4%; P=.57), the researchers said.
After a median of 12 months, the cumulative incidence of stroke was higher in patients with new-onset AF when compared with those without new-onset AF (13.6% vs. 3.2%; HR=4.32; 95% CI, 1.08-17.28). Similarly, data showed that the cumulative incidence of the composite of stroke/systemic embolism was also higher in the new-onset AF group (15.9% vs. 3.2%; HR=5.0; 95% CI, 1.29-19.35). Again, mortality did not differ significantly between groups (15.9% for patients with new-onset AF and 21.3% for patients without new-onset AF; P=.58).
“Future studies will have to determine the potential usefulness of implementing preventive strategies to reduce the occurrence of new-onset AF and its potentially devastating consequences in the setting of TAVI,” the researchers wrote.
Disclosure: Several researchers report serving as consultants for Edwards Lifesciences and St. Jude Medical.
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The report summarized here by Amat-Santos is an important, previously unrecognized finding of frequent AF peri-TAVI. Use of continuous in-hospital monitoring was important to their observation. The finding of episodic AF early post-TAVI is potentially a contributing factor to the reported increased stroke risk for TAVI. A better understanding of the frequency and significance of AF could lead to relevant, perhaps individualized changes in the current approach to post-procedure anticoagulation. However, there are important cautions to be noted. First, the number of adverse events is small. Second, there was a high proportion of transapical procedures not consistent with the more usual, and probably preferral transfemoral approach. Finally, this report includes a single device, the Edwards SAPIAN prosthesis, so it is unclear if the observation is related to a specific device or insertion approach or whether the findings are more applicable to all TAVI procedures. In summary, the report documents an important finding. More and larger data collections involving all prostheses will be critical to fully understand the true frequency and significance of AF post TAVI.
– George W. Vetrovec,
MD
Cardiology Today Editorial Board member
Dislcosure: Dr. Vetrovec reports no relevant financial disclosures.
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