Atrial Fibrillation Is Associated With Mortality in Intermediate Surgical Risk Patients With Severe Aortic Stenosis: Analyses From the PARTNER 2A and PARTNER S3i Trials

Michael I Brener, Isaac George, Ioanna Kosmidou, Tamim Nazif, Zixuan Zhang, Jose M Dizon, Hasan Garan, S Chris Malaisrie, Raj Makkar, Michael Mack, Wilson Y Szeto, William F Fearon, Vinod H Thourani, Martin B Leon, Susheel Kodali, Angelo B Biviano, Michael I Brener, Isaac George, Ioanna Kosmidou, Tamim Nazif, Zixuan Zhang, Jose M Dizon, Hasan Garan, S Chris Malaisrie, Raj Makkar, Michael Mack, Wilson Y Szeto, William F Fearon, Vinod H Thourani, Martin B Leon, Susheel Kodali, Angelo B Biviano

Abstract

Background The impact of atrial fibrillation (AF) in intermediate surgical risk patients with severe aortic stenosis who undergo either transcatheter or surgical aortic valve replacement (AVR) is not well established. Methods and Results Data were assessed in 2663 patients from the PARTNER (Placement of Aortic Transcatheter Valve) 2A or S3i trials. Analyses grouped patients into 3 categories according to their baseline and discharge rhythms (ie, sinus rhythm [SR]/SR, SR/AF, or AF/AF). Among patients with transcatheter AVR (n=1867), 79.2% had SR/SR, 17.6% had AF/AF, and 3.2% had SR/AF. Among patients with surgical AVR (n=796), 71.7% had SR/SR, 14.1% had AF/AF, and 14.2% had SR/AF. Patients with transcatheter AVR in AF at discharge had increased 2-year mortality (SR/AF versus SR/SR; hazard ratio [HR], 2.73; 95% CI, 1.68-4.44; P<0.0001; AF/AF versus SR/SR; HR, 1.56; 95% CI, 1.16-2.09; P=0.003); patients with SR/AF also experienced increased 2-year mortality relative to patients with AF/AF (HR, 1.77; 95% CI, 1.04-3.00; P=0.03). For patients with surgicalAVR, the presence of AF at discharge was also associated with increased 2-year mortality (SR/AF versus SR/SR; HR, 1.93; 95% CI, 1.25-2.96; P=0.002; and AF/AF versus SR/SR; HR, 1.67; 95% CI, 1.06-2.63; P=0.027). Rehospitalization and persistent advanced heart failure symptoms were also more common among patients with transcatheter AVR and surgical AVR discharged in AF, and major bleeding was more common in the transcatheter AVR cohort. Conclusions The presence of AF at discharge in patients with intermediate surgical risk aortic stenosis was associated with worse outcomes-especially in patients with baseline SR-including increased all-cause mortality at 2-year follow-up. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01314313 and NCT03222128.

Keywords: aortic stenosis; atrial fibrillation; transcatheter aortic valve replacement.

Conflict of interest statement

George is a consultant for MitreMedical, CardioMech, WL Gore, Atricure, Neptune Medical. Nazif is a consultant for Edwards Lifesciences, Medtronic, Boston Scientific. Malaisrie is a consultant for Edwards Lifesciences, Medtronic, Abbott. Makkar reports research grants from Edwards Life Sciences, Abbott, Medtronic and Boston Scientific; personal proctoring fee from Edwards Life Sciences; and travel support from Edwards, Abbott and Boston Scientific. Mack reports institutional research support (no direct financial compensation) from Edwards Lifesciences. Thourani reports research funding and consulting for Abbott, Allergen, Boston Scientific, Cryolife, Edwards Lifescience, Gore, Jenavalve. Leon reports institutional research support (no direct financial compensation) from Edwards Lifesciences, Medtronic, Boston Scientific, Abbott. Consultant/Advisory Board for Medtronic, Boston Scientific, Gore, Meril Lifesciences, and Abbott. Kodali reports institutional research support (no direct financial compensation) from Edwards Lifesciences, Medtronic, Abbott. Consultant for Abbott, Admedus, Meril Lifesciences. Equity options from Biotrace Medical and Thubrikar Aortic Valve, Inc. Biviano is on the Medical Advisory Board for Biosense Webster and Boston Scientific. The remaining authors have no disclosures to report.

Figures

Figure 1. Flow diagram illustrating the study…
Figure 1. Flow diagram illustrating the study cohort.
The final study cohort included 2663 individuals, 1867 TAVR recipients and 796 SAVR recipients. AF indicates atrial fibrillation; PARTNER, Placement of Aortic Transcatheter Valve; SAVR, surgical aortic valve replacement; SR, sinus rhythm; and TAVR, transcatheter aortic valve replacement.
Figure 2. Major clinical outcomes for TAVR…
Figure 2. Major clinical outcomes for TAVR and SAVR among rhythm categories.
Kaplan‐Meier curves for TAVR and SAVR for time to (A) all‐cause mortality, (B) any bleeding events, (C) bleeding events landmarked after 30 days, and (D) stroke/transient ischemic attack at 2‐year follow‐up. Panel A illustrates the increased mortality associated with any form of AF post‐procedure. Note the increased bleeding events in SR/AF TAVR patients highlighted in (B). AF indicates atrial fibrillation; HR, hazard ratio; SAVR, surgical aortic valve replacement; SR, sinus rhythm; TAVR, transcatheter aortic valve replacement; TIA, transient ischemic attack.

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