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Kuruvilla et al. Vessel Plus 2022;6:45 https://dx.doi.org/10.20517/2574-1209.2021.122 Page 7 of 9

professional society “quality improvement program” radar screen. Coming from an era where short-term
survival was the foremost concern, POAF is still considered a minor annoyance–rather than a potentially
life-altering event with serious implications for future adverse clinical outcomes and increased costs. Now
that these patients survive longer, entirely overlooking the topic of arrhythmias, as the most frequently
occurring post-TAA complication, seems no longer tenable and justifies the development of pre-TAA/post-
TAA POAF-focused consensus standards.

CONCLUSION
For TAA procedures, the most common place complication occurring is POAF. For the published literature
as of September 6, 2021, this comprehensive literature review identified only a handful of articles reporting
pre-/post-TAA AF rates. Of these, the TAA-specific risk factors associated with increased POAF included:
older age, gender, cardiac dysfunction, and the type of aortic procedure (e.g., aortic arch repairs). In this
search, several historical risk factors associated with POAF for other cardiac surgical procedures had not yet
been associated with the post-TAA procedural risk of POAF. The missing POAF-related traditional risk
factors included hypertension, coronary artery disease, diabetes, and congestive heart failure. To date,
moreover, no thoracic endovascular aortic repair publications were found on this pre-operative AF or
POAF topic; thus, this lack of evidence-based literature to drive future TAA patient care represents a very
serious clinical concern.

Given the paucity of TAA AF publications, pre- and post-TAA AF rates were not documented in the
contemporaneous literature; moreover, TAA patients’ rates for post-discharge AF recurrences were not
reported. Given the lack of TAA patients’ data-driven AF findings, clinicians have very little evidence to
establish their expectations for internal TAA quality assurance initiatives. Importantly, TAA POAF
prophylactic and treatment strategies have not yet been thoroughly evaluated. No TAA-focused patient
clinical trials were found to document the effectiveness of standard POAF prophylactic approaches or
[13]
POAF-related treatments (e.g., beta-blocker use pre-operatively) used in other cardiac surgical patient
populations. Similarly, comparisons of POAF rate control vs. rhythm control strategies have not yet been
published focused specifically on TAA patients. Due to the lack of TAA-specific AF studies, clinicians
treating TAA patients will need to proceed in the interim applying the research findings published for other
cardiac surgical patient populations.

TAA repair or arch replacement procedures are at high risk for bleeding complications; therefore, efforts to
avoid post-TAA POAF anticoagulation are now opportune for future investigation. In other cardiac surgery
populations (e.g., CABG patients), specific POAF treatments (i.e., beta-blockers, amiodarone) have been
documented to significantly reduce POAF rates . Although beta-blocker appropriateness has not yet been
[18]
rigorously evaluated for TAA-related procedures, the recent clinical practice standards include this strategy.
In light of the promotion of recent TAA clinical practice guidelines, this lack of data-driven evidence for
specific POAF therapies for TAA patients should raise a call to arms.

In conclusion, a TAA knowledge chasm exists regarding atrial fibrillation patients’ care. Given this
challenge, additional TAA patient research appears urgently needed to identify, manage, and improve the
future quality of care for this vulnerable, post-TAA POAF “at risk” patient population.

DECLARATIONS
Author’s contributions
Study conception and design: Kuruvilla AS, Agha S, Yaligar A, Tannous HJ, McLarty AJ, Shroyer AL,
Bilfinger TV