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Evaluation of the Incidence of New-Onset Atrial Fibrillation After Aortic Valve Replacement

Educational Objective
To understand the incidence and outcome when atrial fibrillation complicates post treatment transcatheter aortic valve implantation and aortic valve replacement care.
1 Credit CME
Key Points

Question  What is the incidence and prognostic implication of new-onset atrial fibrillation after transcatheter aortic valve implantation and surgical aortic valve replacement?

Findings  In this population-based study, new-onset atrial fibrillation was present in roughly 50% of hospitalizations for transcatheter aortic valve implantation and aortic valve replacement. Hospitalizations with new-onset atrial fibrillation were associated with higher in-hospital mortality compared with transcatheter aortic valve implantation and aortic valve replacement hospitalizations without new-onset atrial fibrillation.

Meaning  The high incidence of atrial fibrillation after transcatheter aortic valve implantation and aortic valve replacement should be discussed during the consent process and prompt shared patient-physician decision making regarding the potential need for anticoagulation after aortic valve procedures.

Abstract

Importance  Data on the burden of new-onset atrial fibrillation after transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (AVR) is limited mostly to small series or post hoc analyses of clinical trials.

Objectives  To evaluate the incidence of new-onset atrial fibrillation and assess the incidence of in-hospital mortality associated with new-onset atrial fibrillation after TAVI and AVR.

Design, Setting, and Participants  In this population-based observational study using the National Inpatient Sample and a validation cohort from the New York state inpatient database, the National Inpatient Sample was queried from January 1, 2012, to September 30, 2015, and the New York state inpatient database was queried from January 1, 2012, to December 31, 2014. Hospitalizations of adults undergoing TAVI or isolated AVR were examined. The incidence of in-hospital mortality across groups with new-onset atrial fibrillation was assessed in the National Inpatient Sample cohort using multivariable logistic regression modeling. Statistical analysis was conducted from August 20, 2018, to March 19, 2019.

Main Outcomes and Measures  The primary outcome was the occurrence of new-onset atrial fibrillation, which was identified by excluding hospitalizations in which atrial fibrillation was present on admission. The secondary outcome was in-hospital mortality in TAVI and AVR hospitalizations with and without new-onset atrial fibrillation.

Results  A total of 48 715 TAVI hospitalizations (47.4% women and 52.6% men; mean [SD] age, 81.3 [8.1] years; 82.3% white) and 122 765 AVR hospitalizations (39.0% women and 61.0% men; mean [SD] age, 67.8 [12.0] years; 78.0% white) were identified. New-onset atrial fibrillation occurred in 50.4% of TAVI hospitalizations and 50.1% of AVR hospitalizations. In the multivariable-adjusted model, TAVI and AVR hospitalizations with new-onset atrial fibrillation had higher odds of in-hospital mortality compared with hospitalizations without new-onset atrial fibrillation (TAVI: odds ratio, 1.57; 95% CI, 1.21-2.04; and AVR: odds ratio, 1.36; 95% CI, 1.08-1.70). The results were then confirmed with the New York state inpatient database, which contains a present on arrival indicator. The incidence of new-onset atrial fibrillation was 14.1% (244 of 1736 hospitalizations) after TAVI and 30.6% (1573 of 5141 hospitalizations) after AVR in the New York state inpatient database.

Conclusions and Relevance  In this large nationwide study, a substantial burden of new-onset atrial fibrillation was observed after TAVI and AVR. The incidence of new-onset atrial fibrillation was higher after AVR than after TAVI in a patient-level state inpatient database.

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Article Information

Accepted for Publication: January 21, 2019.

Corresponding Author: Pankaj Arora, MD, Division of Cardiovascular Disease, University of Alabama at Birmingham, 1670 University Blvd, Volker Hall B140, Birmingham, AL 35294 (parora@uabmc.edu).

Published Online: June 3, 2019. doi:10.1001/jamainternmed.2019.0205

Author Contributions: Drs Kalra and Patel had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Kalra, Patel, Doshi, P. Arora.

Drafting of the manuscript: Kalra, Patel, Doshi, P. Arora.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Patel, Doshi.

Obtained funding: P. Arora.

Administrative, technical, or material support: Kalra, Patel, P. Arora.

Supervision: Kalra, G. Arora, P. Arora.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr P. Arora is supported by American Heart Association Career Development Award 18CDA34110135. Dr Patel is supported by National Institutes of Health grant 5T32HL129948-02.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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