Atrial Fibrillation Management During Surgical vs Transcatheter Aortic Valve Replacement

BACKGROUND Societal guidelines support atrial fibrillation (AF) treatment during surgical aortic valve replacement (SAVR). Recently, many low-intermediate risk patients with AF are managed by transcatheter aortic valve replacement (TAVR). Therefore, we evaluated longitudinal outcomes in these populations. METHODS The United States Centers for Medicare and Medicaid Services inpatient claims database was evaluated for all beneficiaries with AF undergoing TAVR or SAVR with/without AF treatment (2018-20). Treatment of AF included concomitant left atrial appendage obliteration with/without surgical ablation, or endovascular appendage occlusion and/or catheter ablation at any time. Diagnosis-related group and International Classification of Diseases 10th revision codes defined procedures with doubly robust risk-adjustment across each group. RESULTS A total of 24,902 patients were evaluated (17,453 TAVR; 7,449 SAVR). Of patients undergoing SAVR, 3,176 (42.6%) underwent AF treatment (SAVR+AF). Only 656 (4.5%) TAVR patients received AF treatment. Comparing well balanced SAVR+AF vs SAVR vs TAVR, there were no differences in in-hospital incidence of renal failure, bleeding, or stroke but increased pacemakers (OR 3.45, p<0.0001) and vascular injury (OR 9.09, p<0.0001) in TAVR and higher hospital mortality (OR 4.02, p<0.0001) in SAVR+AF. SAVR+AF was associated with lower readmission for stroke compared to SAVR alone (HR 0.87, p=0.029) and TAVR (HR 0.68, p<0.0001) and improved survival vs TAVR (HR 0.79, p=0.019). CONCLUSIONS In Medicare beneficiaries with AF requiring aortic valve replacement, SAVR+AF was associated with improved longitudinal survival and freedom from stroke compared to TAVR. SAVR with AF treatment should be considered first-line therapy for patients with AF requiring aortic valve replacement.