New-onset Late AF Is Uncommon After Surgical Aortic Valve Replacement
Key findings
- This retrospective study was designed to determine predictors of late atrial fibrillation (AF) after surgical aortic valve replacement (SAVR) with the goal of identifying which patients should have a prophylactic anti-arrhythmia procedure with SAVR
- Of 1,014 patients with no preoperative AF who underwent SAVR, 401 (40%) had at least one electrocardiogram available at Massachusetts General Hospital during the first three to 12 months after surgery and 16 (4%) had new-onset late AF diagnosed
- Multivariable logistic regression was not performed; on univariable analysis, the development of late AF was significantly associated with urgent or emergent surgery (OR, 3.45), higher preoperative creatinine level (OR, 1.37), and advanced age (OR, 1.06)
- Considering the low risk of late AF after SAVR (4%), surgeons should be very circumspect about performing concurrent prophylactic tissue ablation or ligation/amputation of the left atrial appendage
A current debate among cardiac surgeons is whether patients with no history of preoperative atrial fibrillation (AF) should have a prophylactic anti-arrhythmia procedure at the time of coronary bypass or valve surgery. Less invasive technologies are now available, but even these interventions impose additional operative risks that must be balanced with potential benefits.
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Thoralf M. Sundt, MD, chief of the Division of Cardiac Surgery at Massachusetts General Hospital, Chin Siang Ong, MBBS, PhD, a research fellow in the division, and colleagues studied predictors of late-onset AF after surgical aortic valve replacement (SAVR), hoping to determine which patients should be considered for a prophylactic concurrent procedure.
In the Journal of Cardiac Surgery, they report finding only a low risk of late AF. They interpret their results as providing no support for pulmonary vein isolation or left atrial appendage ligation/amputation at the time of SAVR.
Methods
The research built on a previous retrospective study at Mass General, published in The Journal of Thoracic and Cardiovascular Surgery, in which older age and left atrial enlargement were identified as risk factors for prolonged new-onset AF after SAVR. "Prolonged" was defined as persisting for at least one month beyond the 30th postoperative day; follow-up did not continue after two months postoperatively.
The new study included patients from the previous cohort, and the start date remained July 2011. The end date was extended from June 2017 to October 2019 and the outcome of interest was new-onset late AF, diagnosed within three to 12 months after surgery.
Prevalence and Predictors of Late AF
Of 1,014 patients with no preoperative AF who underwent SAVR, 401 (40%) had at least one electrocardiogram (ECG) available at Mass General during that three- to 12-month interval. 16 (4%) had new-onset late AF diagnosed.
Because of the small number of patients with late AF, multivariable logistic regression was not performed. On univariable logistic regression, the development of late AF was associated with:
- Urgent or emergent surgery (OR, 3.45; P=0.021)
- Higher preoperative creatinine level (OR, 1.37; P=0.024)
- Advanced age (OR, 1.06; P=0.026)
Comparison of Patients With and Without ECGs
Since most of the cohort did not have ECGs available, the researchers compared them with the 401 patients who did. The two groups were not significantly different on any characteristic associated with late AF in the univariable analysis.
Recommendation
Because the risk of late AF after SAVR is so low, surgeons should perform concurrent prophylactic tissue ablation or ligation/amputation of the left atrial appendage selectively, if at all.
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