New-Onset AF Not Uncommon After Mitral TEER

Roughly one out of every 28 patients who undergo transcatheter edge-to-edge repair (TEER) for mitral regurgitation will make a return trip to the hospital for new-onset atrial fibrillation (AF), a retrospective study shows.

This groups tends to be sicker at the time of TEER compared with patients who either already have AF or don’t have AF at any point. Moreover, the presence of chronic kidney disease, fluid and electrolyte disorders, or heart failure identify those who are at greater risk of developing new-onset AF after the procedure.

“These are predictors that can be screened for,” lead author Fabio Lima, MD (Warren Alpert Medical School of Brown University, Providence, RI), told TCTMD.

Regarding new-onset AF, “a lot of us sometimes like to think of it as a very benign, low-key diagnosis, but it’s a signal that something’s up with the heart: the physiology is distorted. I think it’s a diagnosis that we should chase after and try to minimize as much as possible,” Lima added, noting that studies on mitral valve repair, including surgery, and TAVI show that it’s important to minimize occurrence of the arrhythmia.

Moving forward, Lima said, “we need to develop innovation in our approaches to transcatheter repairs so that we can restore normal physiology as much as possible and prevent A-fib as much as possible.”

The findings were published online this week in the American Journal of Cardiology.

Prior studies have shown that many patients undergoing TEER for mitral regurgitation (MR)—around one-half to two-thirds—have AF at the time of the procedure, and that these patients fare worse than others. But there’s limited information on new-onset AF after the procedure.

It’s a signal that something’s up with the heart: the physiology is distorted. Fabio Lima

For the current study, Lima and colleagues turned to the Nationwide Readmissions Database, examining data on an estimated 6,861 patients who underwent mitral TEER and no other cardiac procedures between 2016 and 2018. The database doesn’t allow for the differentiation between degenerative and functional MR.

Most patients (60.3%) had AF during the index hospitalization and another 36.3% didn’t have AF detected at any point during the study period. The remaining 3.5% developed new-onset AF within 6 months of the procedure, with many (37%) presenting in the first 30 days. The median time from TEER to readmission for new-onset AF was 47 days.

The patients who went on to develop AF had longer and costlier index hospitalizations, and also had a heavier comorbidity burden—the mean Charlson comorbidity score was 2.7 in the new-onset AF group versus 2.3 in the other two groups.

There were three baseline factors independently associated with the development of AF after TEER:

• Chronic kidney disease (OR 1.51; 95% CI 1.03-2.20)
• Fluid and electrolyte disorders (OR 1.59; 95% CI 1.01-2.52)
• Heart failure (OR 1.86; 95% CI 1.01-3.44)

The investigators note that these factors have been linked to AF in prior studies, too. One analysis showed a postprocedural MR grade greater than 2+ was present in 38.5% of patients who went on to develop new AF. “Clinicians should be evaluating for these disease conditions [before TEER] and screening for after-procedural MR grade, coupled with close follow-up in the short-term, as a potential means to minimize the readmission for these patients and their risk for new-onset AF,” they say.

By definition, all patients with new-onset AF were readmitted in the first 6 months. But when the researchers examined return trips to the hospital for non-AF reasons, the patients who developed new AF had a readmission rate in between those seen in the other two groups, with the highest rate observed in patients with AF at baseline. Across all three groups, the top causes of readmission were hypertensive complications and heart failure.

 The true burden of new-onset AF after TEER is unknown because patients aren’t always screened for the problem during follow-up visits, Lima observed. “It might be a lot higher than we think,” he said, adding, however, that an analysis of the TVT Registry provided an estimate similar to what was shown here.

He and his colleagues say it’s possible that the occurrence of new-onset AF is reduced by using transcatheter versus surgical repair of the mitral valve. In the EVEREST II trial, they point out, 31% of patients who underwent surgical repair developed permanent or persistent AF.

“Surgical MV repair involves significantly more invasive intervention and physiologic stressors, which may predispose triggering AF,” they propose. “Thus, there is potential that TEER may offer a lower likelihood of developing new-onset AF and maintaining normal sinus rhythm compared with a surgical approach. This concept should be investigated further in future studies.”