Catheterization and Cardiovascular Interventions 85:478–479 (2015)

Editorial Comment Atrial Fibrillation After Transcatheter Aortic Valve Replacement: Room for Improvement Amar Krishnaswamy,* MD, and E. Murat Tuzcu, MD Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio

Key Points

 Demonstrates the burden of AF in patients undergoing TAVR  Highlights the association of AF with adverse outcomes and the low rate of anticoagulation for patients with AF after TAVR  Provides a background for consideration of left atrial appendage occlusion devices in patients with AF after TAVR

Transcatheter aortic valve replacement (TAVR) provides an important treatment for aortic stenosis (AS) patients considered inoperable or at high-risk for complications with surgical aortic valve replacement. The postprocedural care of these patients is paramount to the long-term success of TAVR given their average age and comorbidities. As such, understanding the contributors to morbidity and mortality provides important insights into goals for their subsequent care. In this regard, the current report by Barbash and coworkers highlights the importance of atrial fibrillation (AF) among patients undergoing TAVR. Of the 371 patients treated, 143 (39%) had AF at baseline, and 46 patients (20%) developed new-onset AF (NOAF). Independent predictors of NOAF included transapical (TA) access and hemodynamic instability during the procedure. Among patients with any AF, long-term outcomes were worse, and NOAF was associated with a higher rate of postprocedural complications including acute renal failure, heart failure, and need for prolonged mechanical ventilation. It is difficult to establish causality between AF and most adverse outcomes (other than stroke) in patients C 2015 Wiley Periodicals, Inc. V

undergoing surgical aortic valve replacement (SAVR) or TAVR. Nevertheless, there are a number of important messages from this study. The presence of baseline AF in TAVR patients is substantially higher than that among patients undergoing SAVR in large series. This is likely the result of the higher-risk population studied, with a significant proportion of patients having AF risk factors such as advanced age, hypertension, diabetes, and so forth. On the other hand, NOAF in this TAVR group was less than that seen in other surgical series, though other investigators have reported a higher rate of postprocedural AF [1]. As the presence and/or development of AF is a known risk for worse early- and late-outcomes, demonstrating the scope of the problem important [2]. In the postprocedural short-term, the development of AF should be closely monitored and aggressively managed to avoid hemodynamic compromise or precipitate heart failure. The association of both baseline and NOAF with stroke is well known, and stroke is an important ongoing risk in patients after TAVR [3]. Despite the fact that the majority of strokes in TAVR patients occur peri-procedurally, there is a significant continued hazard for cerebrovascular events. It stands to reason that some of these strokes are due to cardioembolic stroke in patients with AF, and there was a threefold higher incidence of out-of-hospital stroke in the AF group. Therefore, the finding that only a small minority of patients in this study received long-term anticoagulation is of concern. While specific reasons for the avoidance of warfarin or the novel oral anticoagulants (NOACs) are not provided, it can be surmised that high bleeding risk precluded the use of these agents, an issue that is often encountered in the care of these patients. This last point deserves special consideration. Various approaches to percutaneous left atrial appendage Conflict of interest: Nothing to report. *Correspondence to: E. Murat Tuzcu, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH. E-mail: [email protected] Received 19 December 2014; Revision accepted 21 December 2014 DOI: 10.1002/ccd.25803 Published online 9 February 2015 in Wiley Online Library (wileyonlinelibrary.com)

Atrial Fibrillation After Transcatheter Aortic Valve Replacement

occlusion (LAAO) for patients with nonvalvular AF have recently been developed. Among patients who are not candidates for anticoagulation, these occlusion techniques substantially reduce the risk of stroke in comparison to predicted stroke risk based upon the well-validated CHADS2 score [4]. Therefore, some of the patients in this study who did not receive anticoagulation may have been appropriate candidates for device therapy to reduce their risk of cardioembolic stroke. In this regard, our group recently demonstrated that almost two-thirds of patients with AS and AF do not have associated mitral valve disease and may therefore be candidates for percutaneous LAAO [5]. Future trials of percutaneous LAAO in this patient group may therefore be warranted to establish safety and efficacy of this new technology. This report by Barbash and coworkers highlights the occurrence and importance of AF in patients undergoing TAVR. Their work reminds us that vigilant monitoring of the patients’ rhythm in the postprocedural period may improve in-hospital outcomes, and that long-term rhythm assessment may be important to reducing stroke risk. The use of anticoagulation in TAVR patients with AF is complicated, and many patients present a prohibitive risk for the same. These patients may be appropriate candidates for newly developed percutaneous LAAO strategies.

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REFERENCES 1. Amat-Santos IJ, Rodes-Cabau J, Urena M, DeLarochelliere R, Doyle D, Bagur R, Villeneuve J, Cote M, Nombela-Franco L, Philippon F, Pibarot P, Dumont E. Incidence, predictive factors, and prognostic value of new-onset atrial fibrillation following transcatheter aortic valve implantation. J Am Coll Cardiol 2012;59:178–188 2. Urena M, Hayek S, Cheema AN, Serra V, Amat-Santos IJ, Nombela-Franco L, Ribeiro HB, Allende R, Paradis JM, Dumont E, Thourani VH, Babaliaros V, Francisco Pascual J, Cortes C, Garcia Del Blanco B, Philippon F, Lerakis S, Rodes-Cabau J. Arrhythmia burden in elderly patients with severe aortic stenosis as determined by continuous ECG recording: Towards a better understanding of arrhythmic events following transcatheter aortic valve replacement. Circulation. 2014 Dec 2. pii: CIRCULATIONAHA. 114.011929. [Epub ahead of print]. 3. Nombela-Franco L, Webb JG, de Jaegere PP, Toggweiler S, Nuis RJ, Dager AE, Amat-Santos IJ, Cheung A, Ye J, Binder RK, van der Boon RM, Van Mieghem N, Benitez LM, Perez S, Lopez J, San Roman JA, Doyle D, Delarochelliere R, Urena M, Leipsic J, Dumont E, Rodes-Cabau J. Timing, predictive factors, and prognostic value of cerebrovascular events in a large cohort of patients undergoing transcatheter aortic valve implantation. Circulation 2012;126:3041–3053 4. Bajaj NS, Parashar A, Agarwal S, Sodhi N, Poddar KL, Garg A, Tuzcu EM, Kapadia SR. Percutaneous left atrial appendage occlusion for stroke prophylaxis in nonvalvular atrial fibrillation: A systematic review and analysis of observational studies. JACC Cardiovasc Interv 2014;7:296–304 5. Parashar A, Devgun J, Agarwal S, Thomas J, Patel A, Tuzcu E, Krishnaswamy A, Kapadia S. Atrial fibrillation in patients with aortic stenosis: Is percutaneous left atrial appendage closure an option? J Am Coll Cardiol 2014;64:B52

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

Atrial fibrillation after transcatheter aortic valve replacement: room for improvement.

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