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Novotny et al. Vessel Plus 2022;6:51 https://dx.doi.org/10.20517/2574-1209.2021.139 Page 9 of 15

Table 4. Multivariable model findings for STS 30-day readmission endpoint
Odds ratio 95% confidence interval P-value
Pre-operative AF/AFL 1.15 0.60-2.19 0.681
Surgery type: viv-TAVR vs. r-SAVR 0.44 0.21-0.91 0.027
Cerebrovascular disease 2.54 1.23-5.25 0.012
Age 1.02 0.99-1.05 0.117
Elixhauser readmission score 1.02 0.997-1.04 0.102

Model C-index = 0.682. STS: Society of thoracic surgeons; AF/AFL: atrial fibrillation/flutter; r-SAVR: Redo surgical aortic valve replacement; viv-
TAVR: valve-in-valve transcatheter aortic valve replacement.

AVR study did not find that pre-operative AF/AFL increased the risk of 30-day readmission or the risk of
incurring the STS MM composite comprised of major complications and/or mortality.

These repeat AVR-related findings do not support the previously reported negative impacts of AF/AFL in
first-time AVR [8-10,21-24] . Several theories for worse outcomes with pre-operative AF/AFL have been proposed.
AF may be a consequence of more chronic and severe aortic valve disease and may lead to reduced cardiac
output, both of which could contribute to increased resource utilization and worsened outcomes .
[8]
Additionally, AF is known to result in atrial fibrosis and structural remodeling that may contribute to
longer-term cardiovascular mortality which may require additional post-procedural care [10,25] .

For r-SAVR patients, baseline demographics and medical conditions differed between AF/AFL versus non-
AF/AFL patient sub-groups. Pre-operative AF/AFL patients in the r-SAVR cohort were significantly older
and less commonly of Hispanic ethnicity, but had higher rates of cerebrovascular disease history, permanent
pacemaker/implantable cardiac defibrillator, hyperlipidemia, rheumatic heart disease, fluid and electrolyte
disorders, and pulmonary hypertension. Among viv-TAVR patients, those with and without pre-operative
AF/AFL generally had similar demographics. AF/AFL viv-TAVR patients had lower rates of chronic
obstructive pulmonary disease compared to non-AF/AFL patients. Notably, Elixhauser comorbidity scores
were similar between patients with and without pre-operative AF/AFL for both r-SAVR and viv-TAVR,
indicating relatively comparable comorbidity burdens.

There was no association between 30-day readmission or the MM composite endpoint with AF/AFL for
either r-SAVR or viv-TAVR. However, r-SAVR AF/AFL patients had higher prolonged ventilation, cardiac
arrest, and post-operative length of stay days than the non-AF/AFL group. Previous literature has found
preoperative AF associated with a longer length of stay for both first-time SAVR and TAVR . In contrast
[11]
to prior publications regarding SAVR and TAVR outcomes, the current study found no difference in
postoperative stroke rates between AF/AFL versus non-AF/AFL patients . Use of perioperative and/or
[26]
postoperative anticoagulation was unknown but may have contributed to this finding.

Multivariable analyses evaluating the impact of AF/AFL yielded several predictors of these study endpoints.
Black race and Elixhauser mortality score predicted the composite endpoint; this is consistent with previous
studies showing increased risk of prolonged ventilation, renal failure, and need for reoperation after first-
[27]
time SAVR in patients of black race . However, the impact of black race on first-time TAVR outcomes is
not clear. Patients of black race were shown to have increased post-TAVR intubation and hemodynamic
instability . In contrast, other published reports did not find a similar racial association with major
[28]
complications or mortality [29,30] . Future research, therefore, now appears warranted to evaluate potential
r-AVR racial disparities in clinical and resource outcomes.