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Dokko et al. Vessel Plus 2022;6:53 https://dx.doi.org/10.20517/2574-1209.2022.11 Page 11 of 15

For first-time AVR procedures, older age was reported as the strongest independent predictor of
POAF/AFL; this may be due to structural changes of the heart over time, such as fibrosis and hypertrophy,
that affect nodal conduction, and increased comorbidity rates associated with advanced age [16,22-24] . Cerebral
vascular disease was also shown to be associated with POAF/AFL as shown in previous studies and is likely
an indicator of worse heart health [25,26] .

In this New York State’s SPARCS database analysis, patients who underwent ViV-TAVR were older than
r-SAVR patients and had higher rates of other risk factors. Interestingly, the r-SAVR patients’ age increased
over time. Comparing the earlier study time period (2005-2011) to the latter study time period (2012-2018),
the r-SAVR patients’average age increased from 55.0 ± 13.1 years to 63.5 ± 13.6 years, P < 0.01. These
age-related trends may be explained, at least in part, that aortic stenosis was historically a disease
predominately diagnosed in the elderly. In more recent times, aortic stenosis appears to be pursued much
more vigorously in younger patients.

Comparing ViV-TAVR average ages (2012 to 2018), however, the r-SAVR patients (mean ± SD; 63.5 ± 13.6)
were still substantially younger than the ViV-TAVR patients (mean ± SD; 74.0 ± 11.6). Although ViV-
TAVR was a less invasive procedure with lower risks of adverse outcomes compared to r-SAVR, the Food
and Drug Administration’s initial ViV-TAVR approval was authorized only for high-risk patients [27-29] .
Future research appears warranted to identify if these historical age differences between r-SAVR and Viv-
TAVR patients will persist following later FDA approvals for TAVR use in intermediate and lower-risk
patient sub-populations. With the question of initial TAVR valve durability still pending, however, the
pendulum between initial TAVR vs. SAVR selection -- and hence the relative risk profile between ViV-
TAVR and r-SAVR patients - may likely swing back and forth until this issue is firmly settled.

For first-time AVR procedures, POAF/AFL has been associated with worse mortality, higher rates of stroke,
increased length of stay, and readmission [10,16,18,30,31] . Historically, the impact of POAF/AFL in r-AVR patients
has not been similarly investigated. For this New York State population, POAF/AFL versus non-POAF/AFL
patients did not have different rates of MM or stroke, which may require longer follow-up (beyond 30 days)
to observe the full impact of POAF/AFL upon r-AVR patients’ survival. As an important consideration,
however, r-AVR patients with POAF/AFL were more likely to be readmitted within 30-days, as well as to
have longer hospitalizations. Similarly in a study by Jeong et al. comparing the impact of POAF/AFL in
first-time AVR patients, admission due to heart failure within 1-year follow-up was significantly higher in
patients with POAF/AFL in both SAVR and TAVR groups . Given the inherent complexities of repeated
[30]
procedures, therefore, the higher 30-day readmission rates for POAF/AFL patients may be due to either
post-procedural complications (i.e., reflecting myocardial damage) or unmeasured risk factors that may be
associated with increased resource utilization.

In this r-AVR study, the MM predictors found were consistent with those previously reported for first-time
AVR patients. Black race was documented in this New York Statewide r-AVR population to be predictive of
MM; per a prior publication of 991 TAVR patients, this may be due to black race also being associated with
a patient-prosthesis mismatch . Based on a study by Taylor et al., black patients who underwent a mitral
[32]
valve replacement or an AVR were also significantly associated with an increased risk of procedural
complications such as prolonged ventilation, longer postoperative stay, and reoperation for bleeding; these
patients were generally in poorer health compared to white patients, with higher New York Heart
Association class and pulmonary artery pressures and lower ejection fractions . This disparity in health
[33]
outcomes for black patients is likely due to limited access to care despite these patients residing near
hospital centers that perform TAVR, as indicated by Nathan et al. and Bilfinger et al. [34,35] . Elixhauser score,