Late incidence and recurrence of new-onset atrial fibrillation after isolated surgical aortic valve replacement

Comparative evaluation of mechanical and biological prostheses in patients with aortic stenosis

OBJECTIVES

The commonly accepted aortic valve prostheses have been either mechanical or biological. Each type has its advantages and disadvantages, with age being the most widely accepted variable to determine the best option. There is, however, a range between 60 and 70 years where an individualized approach is required.

METHODS

This is a retrospective study. The primary outcome was overall survival based on the type of prosthesis used, stratified by effect modifiers. Association between prosthesis type and mortality rate was evaluated using the incidence rate ratio. Secondary outcomes included cardiovascular survival, postoperative mortality and complications, adjusted for age. Cox regression analysis was performed to account for confounders. Variation in the hazard ratio for death by age was explored by fitting a restricted cubic spline to the interaction between age and valve type. We included all adult patients who underwent surgical aortic valve replacement for severe stenosis in Uruguay from 2011 to 2021. A total of 3944 patients were enrolled; 1708 were females. Median follow-up time was 4.5 years.

RESULTS

Bioprostheses (BP) were associated with higher mortality in males and in patients without statins. When mortality rate was stratified by age, BP were associated with a higher risk in patients younger than 60 and a lower risk in the 70-79 age group.

CONCLUSIONS

BP are associated with worse survival in male patients and in the <60-year-old age group. Gender and statins should be considered when deciding the prosthesis for patients in the 60-69 age group. When the relative survival benefit of BP was analysed, 70 years was identified as the threshold at which their benefit became evident compared to mechanical prostheses.

Posterior cardiac drain for atrial fibrillation after aortic valve replacement

Background

Postoperative atrial fibrillation occurs in 27% to 40% of patients after cardiac surgery. One cause of postoperative atrial fibrillation is pericardial effusion, which can be a significant source of inflammation. In this study, we investigated the effect of a drain placed in a posterior site to the heart to reduce pericardial effusion in the early postoperative period to prevent postoperative atrial fibrillation.

Methods

Participants were patients who underwent initial standby aortic valve replacement at Saga-Ken Medical Centre Koseikan from January 2010 to December 2021. Patients with a history of atrial fibrillation, complex surgery, or emergency surgery were excluded. The patients were divided into two groups: those with a posterior cardiac drain in addition to the usual intrapericardial and subpleural drains from September 2017 (group P) and those without posterior cardiac drain from January 2010 to August 2017 (group N). Multiple logistic regression analysis was performed to evaluate the usefulness of posterior cardiac drain.

Results

Of the 79 patients included the study, 40 were male and groups P and N comprised 27 and 52 patients, respectively. Of the 79 patients, 32 developed postoperative atrial fibrillation; among whom, 7/27 (25.9%) had posterior cardiac drain and 25/52 (48.1%) had no posterior cardiac drain (p = 0.09). When adjusted for body surface area, left ventricular end-diastolic and left atrial diameter, the incidence of postoperative atrial fibrillation was significantly lower in group P than in group N (adjusted odds ratio 0.270, 95% confidence interval 0.077-0.953, p = 0.042). Furthermore, no patient in the group P underwent postoperative thoracentesis in the subanalysis.

Conclusions

The results suggest that early postoperative reduction of pericardial effusion by posterior cardiac drain placement may reduce the incidence of postoperative atrial fibrillation.

A randomized prospective multicenter trial for stroke prevention by prophylactic surgical closure of the left atrial appendage in patients undergoing bioprosthetic aortic valve surgery--LAA-CLOSURE trial protocol

Patients undergoing surgical aortic valve replacement (SAVR) are at high risk for atrial fibrillation (AF) and stroke after surgery. There is an unmet clinical need to improve stroke prevention in this patient population. The LAA-CLOSURE trial aims to assess the efficacy and safety of prophylactic surgical closure of the left atrial appendage for stroke and cardiovascular death prevention in patients undergoing bioprosthetic SAVR. This randomized, open-label, prospective multicenter trial will enroll 1,040 patients at 13 European sites. The primary endpoint is a composite of cardiovascular mortality, stroke and systemic embolism at 5 years. Secondary endpoints include cardiovascular mortality, stroke, systemic embolism, bleed fulfilling academic research consortium (BARC) criteria, hospitalization for decompensated heart failure and health economic evaluation. Sample size is based on 30% risk reduction in time to event analysis of primary endpoint. Prespecified reports include 30-day safety analysis focusing on AF occurrence and short-term outcomes and interim analyses at 1 and 3 years for primary and secondary outcomes. Additionally, substudies will be performed on the completeness of the closure using transesophageal echocardiography/cardiac computed tomography and long-term ECG recording at one year after the operation.