A-fib Signals Worse Prognosis After Aortic Valve Replacement in Intermediate-Risk Patients

Patients who have A-fib detected before or after transcatheter or surgical valve replacement are more likely to die in the next few years.

A-fib Signals Worse Prognosis After Aortic Valve Replacement in Intermediate-Risk Patients

DENVER, CO—Intermediate-risk patients undergoing either transcatheter or surgical aortic valve replacement (SAVR) who have A-fib detected on an ECG before the procedure or at discharge fare worse through 2 years of follow-up, an analysis of the PARTNER 2A and PARTNER 2 S3i studies shows.

At 2 years, the composite rate of death, rehospitalization, or stroke was significantly higher in patients who had A-fib detected than in those who were in sinus rhythm before and after TAVR or SAVR, according to Angelo Biviano, MD, MPH (NewYork-Presbyterian/Columbia University Medical Center, New York, NY).

The findings were similar for death alone, but strokes rates did not differ based on A-fib status, he reported at TCT 2017.

Prior studies established that A-fib is associated with poorer outcomes following TAVR and SAVR in high-risk patients, with increases in 30-day and 1-year mortality and in 1-year rehospitalization, and those findings have now been extended to the intermediate-risk population, Biviano explained.

“This is a high-risk group,” Biviano told TCTMD, referring to those with A-fib, “and we now just need to target treatment strategies better.”

PARTNER 2A and PARTNER 2 S3i Data

To explore the influence of atrial fibrillation, he and his colleagues examined data from the PARTNER 2A trial, which randomized intermediate-risk patients with severe, symptomatic aortic stenosis to TAVR with the Sapien XT valve (Edwards Lifesciences) or surgery, and the PARTNER 2 S3i study, which compared patients undergoing TAVR with the Sapien 3 valve (Edwards Lifesciences) with surgical patients from PARTNER 2A.

The presence of A-fib was defined as atrial fibrillation or flutter on baseline and/or discharge ECG. Of 1,865 patients undergoing TAVR, 79.2% were in sinus rhythm at baseline and discharge, 3.2% had A-fib at discharge only, and 17.5% had A-fib at baseline and discharge. Corresponding figures among the 796 patients undergoing surgery were 71.7%, 14.2%, and 14.1%.

In the TAVR group, patients who had A-fib detected only on the discharge ECG had the highest rates of all-cause mortality (15.3%), cardiovascular mortality (6.8%), and rehospitalization (19.8%) at 1 year, although just the mortality rate was significantly higher compared with patients who remained in sinus rhythm (7.0%; P = 0.02). Rehospitalization was more frequent in patients who had A-fib on both ECGs versus those in sinus rhythm on both time points (17.3% vs 11.2%; P = 0.003).

Rates of cardiovascular mortality, any bleeding, life-threatening/disabling bleeding, and stroke/TIA at 1 year did not differ based on A-fib status in the TAVR group.

In the SAVR cohort, both A-fib groups had significantly higher rates of mortality and rehospitalization at 1 year compared with patients in sinus rhythm on both ECGs (P ≤ 0.03 for all comparisons). Death occurred in 18.2% of those with A-fib on both ECGs, 14.5% of those with A-fib at discharge only, and 8.2% in patients without A-fib. Corresponding rates of rehospitalization were 27.6%, 15.0%, and 10.9%.

As in the TAVR group, there were no differences based on the presence or absence of A-fib in rates of cardiovascular mortality, bleeding, or stroke/TIA at 1 year in the SAVR cohort.

A-fib continued to be associated with worse outcomes at 2 years. The rate of a composite of death, rehospitalization, or stroke was highest in among patients with A-fib at discharge only (45.0%) in the TAVR group and among those with A-fib on both ECGs (41.2%) in the SAVR group.

The presence of A-fib at baseline, discharge, or both independently predicted mortality at 1 or 2 years in both the TAVR and SAVR cohorts.

I think that we’re at the tip of the iceberg in terms of identifying a population at risk, but now we need to sort out the details of how to best treat these patients. Angelo Biviano

Biviano said the question that needs to be answered now—in a prospective fashion—is whether there are strategies that can mitigate the risk associated with A-fib in patients undergoing aortic valve replacement.

“We just don’t have that data yet. I think that we’re at the tip of the iceberg in terms of identifying a population at risk, but now we need to sort out the details of how to best treat these patients,” he told TCTMD.

Currently, there’s a lot of variation in terms of how patients with A-fib are managed after valve replacement, he noted. Rhythm control with cardioversion or antiarrhythmic drugs, anticoagulation, and possibly left atrial appendage occlusion could all come into play.

“However, all of those have potential for complications down the road,” Biviano said. “We don’t yet have a consensus with regard to what’s the best treatment, and so that’s why we need to study it more.”

Sources
  • Biviano A. Atrial fibrillation is associated with increased mortality in intermediate-risk patients undergoing TAVR or SAVR: insights from the PARTNER 2A and PARTNER 2 S3i trials. Presented at: TCT 2017. November 1, 2017. Denver, CO.

Disclosures
  • Biviano reports no relevant conflicts of interest.

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