Comparing outcomes of transcatheter versus surgical aortic valve replacement in patients with atrial arrythmias

Abstract

Abstract Introduction In patients with severe aortic valve stenosis, clinical trials have demonstrated a similar mortality risk with transcatheter aortic valve replacement (TAVR) compared to surgical aortic valve replacement (SAVR) in low to intermediate-risk patients. However, data comparing these procedures in patients with atrial arrhythmias is lacking. Purpose This study aimed to evaluate and compare the in-hospital mortality and outcomes of TAVR and SAVR for severe aortic stenosis in patients with atrial fibrillation or atrial flutter. Methods We performed a retrospective cross-sectional analysis using the 2018 National Inpatient Sample. Patients aged 50 years and older with TAVR or SAVR related hospitalizations were identified. Patients with endocarditis and those undergoing coronary artery bypass grafting or other valvular procedures were excluded. Propensity score matching was utilized to mitigate selection bias. The scoring was based on a multivariate logistic regression model accounting for age, gender, race, hospital type, hospital region, hospital teaching status, median household income, and medical comorbidities. Using 8-to-1-digit match, we paired each admission in TAVR group with one admission in SAVR group. Results In 2018, a total of 3487 TAVRs and 1466 SAVRs were performed in patients who had atrial fibrillation or atrial flutter. TAVR and SAVR had no statistically significant difference in inpatient mortality (0.9% vs 0.8%, p=0.79). However, SAVR was associated with higher odds of cardiogenic shock (OR 1.82; 95% CI 1.41–2.35, p<0.0001), acute kidney injury (OR 2.29; 95% CI 1.77–2.97, p<0.0001), mechanical ventilation (OR 2.06; 95% CI 1.75–2.43, p<0.0001), pneumonia (OR 1.76; 95% CI 1.37–2.28, p<0.0001), pneumothorax (OR 6.38; 95% CI 4.17–9.76, p<0.0001) and postoperative hemorrhage (OR 3.21; 95% CI 2.13–4.85, p<0.0001). On the contrary, SAVR was associated with decreased likelihood of subsequent cardiac conduction disorders (OR 0.63; 95% CI 0.51–0.79, p<0.0001) and pacemaker implantation (OR 0.69; 95% CI 0.49–0.98, p=0.037). SAVR was associated with an increased length of hospitalization (3.9 vs. 8.4 days, p<0.0001), with no difference in medical costs. Conclusion Inpatient mortality for TAVR and SAVR was similar in patients with atrial fibrillation and atrial flutter. TAVR was associated with a lower risk of inpatient complications, indicating greater suitability for high-risk patients. However, clinicians should be cognizant of the increased risk for cardiac conduction disorders after TAVR, necessitating pacemaker implantation. Funding Acknowledgement Type of funding sources: None. Characteristics of the matched cohortForest plot comparing outcomes