Treating AFib patients with TAVR still linked to elevated risks
While the technology and techniques associated with transcatheter aortic valve replacement (TAVR) have advanced over the years, treating patients who present with baseline atrial fibrillation (AFib) is still associated with certain risks, according to new data published in the Canadian Journal of Cardiology.[1] In fact, outcomes are even worse when patients present with permanent AFib as opposed to paroxysmal AFib.
AFib has previously been associated with a negative impact on TAVR outcomes, researchers explained, but most of those studies focused on older-generation devices that are no longer being implanted on patients who present with symptomatic severe aortic stenosis.
“Contemporary TAVR devices have significantly reduced the incidence of adverse outcomes including postprocedural complications as compared to older devices,” wrote first author Siddhartha Mengi, MD, a researcher with the Quebec Heart and Lung Institute and Laval University, and colleagues. “Additionally, the use of a minimalistic transarterial (transcarotid, transaxillary) approach has increased as alternative access, while the transapical and transthoracic routes have decreased. Furthermore, there is widespread expansion of TAVR across the entire surgical risk spectrum, including low-surgical risk patients. This shift has changed the comorbidity burden of TAVR patients and likely influenced the outcome in AFib patients and associated risk factors.”
To learn more, Rodés-Cabau et al. tracked data from nearly 3,500 patients treated with a newer-generation TAVR valve from 2014 to 2023 in Canada or Europe. The mean age was 81.9 years old, and 46.7% were women. All patients presented with baseline permanent (61%) or paroxysmal AFib (39%).
Patients either received a self-expanding Evolut R, Evolut Pro or Evolut Pro+ valve from Medtronic, a self-expanding Accurate NEO or NEO2 valve from Boston Scientific or a balloon-expandable Sapien S3, Sapien Ultra or Sapien Resilia valve from Edwards Lifesciences. Transfemoral TAVR was used in 92.4% of patients, but alternative access was used when viewed as the safest treatment option.
Overall, 3.5% of patients died within 30 days, and a vast majority (3.1%) of those deaths were associated with cardiovascular causes. Other 30-day event rates included 0.8% for heart failure (HF)-related hospitalizations, 2.6% for stroke, 0.6% for myocardial infarction, 26.3% for bleeding events, 18.2% for permanent pacemakers implantation, 5.1% for moderate to severe paravalvular leak and 6.5% for moderate to severe mitral regurgitation.
After a median follow-up period of two years, meanwhile, 36.4% of patients and 51.6% of those deaths were from cardiovascular causes. In addition, 12.1% of patients had a hospitalization related to HF and 15.6% of the total deaths were related to HF.
Age, permanent AFib, chronic kidney disease, anemia, New York Heart Association III or IV HF symptoms and non-transfemoral access were all independently associated with a heightened risk of all-cause death or Hf-related hospitalization following TAVR.
“Notably, acute events including early stroke and early bleeding within 30 days post-TAVR significantly predicted all-cause mortality or HF-related hospitalization at follow-up,” the authors wrote.
Mengi and colleagues noted that TAVR survival for patients with baseline AFib appears to be substantially higher than it was in previous studies focused on early-generation TAVR devices, “suggesting that contemporary devices and refined procedural techniques … may contribute to reduced mortality in patients with AFib undergoing TAVR.”
Another key takeaway from this study was the confirmed relationship between permanent AFib and an increased risk of the composite outcome of death or HF-related hospitalization.
“The differences in all-cause mortality among various AFib patterns may be explained by an electrophysiologic perspective as permanent AFib exhibits more pronounced atrial electrical remodeling, which contributes to the prolongation of AFib, and progressive AFib patterns are often associated with elevated left atrial pressures and structural heart disease,” the authors wrote. “Furthermore, permanent AFib reduces the ventricular filling from the loss of atrial contraction, leading to reduced cardiac output and may predispose to HF, and contribute to overall mortality. This suggests that prior AFib, which is not accounted for in conventional cardiac surgery risk stratification scores like EuroSCORE and the Society of Thoracic Surgeons score, could be included as an independent and significant risk factor in TAVR.”
Click here to read the full analysis in the Canadian Journal of Cardiology, an official journal of the Canadian Cardiovascular Society.
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.