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Page 2 of 15 Dokko et al. Vessel Plus 2022;6:53 https://dx.doi.org/10.20517/2574-1209.2022.11

Bivariately, POAF/AFL was associated with READMIT, but not MM. Correspondingly, multivariable models found
POAF/AFL increased READMIT (OR: 3.12, 95%CI: 1.46-6.65, P < 0.01), but not MM. However, black race (OR:
4.97, 95%CI: 1.61-15.37, P < 0.01) and Elixhauser score (OR: 1.05, 95%CI: 1.02-1.08, P < 0.01) increased risk for
MM.

Conclusion: More common in older and cerebrovascular disease patients, 41% of r-AVR patients with POAF/AFL
had increased READMIT risk; thus, future investigations should focus on improving POAF/AF r-AVR patients’
post-discharge continuity of care.

Keywords: Aortic stenosis, aortic valve replacement, surgical aortic valve replacement, transcatheter aortic valve
replacement, valve-in-valve, repeat surgical aortic valve replacement, atrial fibrillation, atrial flutter

INTRODUCTION
Across all cardiothoracic surgical procedures, new-onset postoperative atrial fibrillation or atrial flutter
(POAF/AFL) occurs commonly. In 2019, surgical aortic valve replacements (SAVR) and transcatheter aortic
valve replacement (TAVR) were the most common treatments for aortic stenosis, with over 130,000 patients
who underwent an initial AVR procedure; since 2011, these aortic valve replacement (AVR) volumes have
dramatically increased . New-onset POAF/AFL is not always a transient condition; even for patients
[1-5]
discharged in normal sinus rhythm, recurrent atrial fibrillation (AF) has been reported up to 5 years
post-SAVR .
[6]

As aortic valves inherently have limited durability, bioprosthetic valves often experience structural
[7]
deterioration within 10-12 years, and thus require repeat procedures . For repeat AVR (r-AVR) patients,
the POAF/AFL incidence was reportedly increased for more invasive procedures (35.5%-60% of SAVR and
10.4%-50.4% of TAVR patients); POAF/AFL has been associated with greater mortality, stroke, and hospital
resource utilization [6,8-18] . For example, one single-center study has shown 63.6% of 22 r-SAVR and 18.2% of
[19]
22 valve-in-valve transcatheter aortic valve replacements (ViV-TAVR) patients to have POAF/AFL . In
spite of these increased r-AVR procedural rates, r-AVR patients’ risk factors associated with POAF/AFL, as
well as the impact of new-onset POAF/AFL upon short-term r-AVR patients’ outcomes, have not been
previously reported. As a novel investigation, therefore, this study was specifically designed to address this
knowledge gap.

Using the New York State’s Statewide Planning and Research Cooperative System (SPARCS) database
records from 2005-2018, this observational, retrospective cohort analysis identified the patient risk factors
predictive of r-AVR POAF/AFL, as well as the POAF/AFL impact upon risk-adjusted 30-day
morbidity/mortality (MM) composite and 30-day readmission (READMIT). After holding other patient
risk factors and procedural details constant, the study’s hypothesis was that POAF/AFL may be an
important post-procedural complication contributing to increased risk of MM and READMIT.

METHODS
Study population
[20]
Within New York, the 2018 population of adults was estimated to be approximately 19 million . Since
2003, the New York State’s SPARCS database has tracked all non-federal hospital-based inpatient and
outpatient care, ambulatory surgery, and emergency room care; patients’ records include their demographic
information, diagnoses, procedures, and outcomes . Using billing codes [Supplementary Tables 1 and 2,]
[21]
the New York State’s SPARCS records for New York State residents undergoing repeat aortic valve (r-AVR)
procedures from January 2005 to November 2018 were extracted. Given that only de-identified SPARCS