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Page 12 of 15 Dokko et al. Vessel Plus 2022;6:53 https://dx.doi.org/10.20517/2574-1209.2022.11

reflecting comorbidity burden in patients undergoing r-AVR procedures was also shown to a predictor of
[36]
MM and was similarly shown in a study by Nagaraja et al examining 40,604 TAVR patients .
CONCLUSION
Affecting 41% of the New York State r-AVR population, the r-AVR POAF/AFL rates are comparable to that
of first-time AVR. Due to the increased risk of READMIT for these patients undergoing r-AVR, the “at
risk” (i.e., older and cerebrovascular patients undergoing r-SAVR) may now be identified for possible
prophylactic treatments such as antiarrhythmic medications post r-AVR procedure. With the increasing
volume of SAVR and TAVR procedures being performed, there is also an increasing trend toward
bioprosthetic valves and performing ViV-TAVR procedures.

Over time, the r-AVR patients’ profiles have changed. In the latter time periods, there were higher
proportions of patients who were older and patients with higher rates of cerebrovascular disease; these
patients were “at risk” of readmission within 30 days. Importantly, black patients and/or patients with high
Elixhauser comorbidity scores should be proactively identified by clinicians as “at risk” populations. With a
focus on targeting these higher-risk r-AVR populations, future clinical trials should investigate innovative
prophylaxis and treatment regimens that might improve the clinical outcomes and reduce the differential
burden of health care costs incurred. Most importantly, post-r-AVR discharge continuity of care and
specialty consultations should be investigated to assure successful convalescence of the POAF/AFL patients.

Limitations
This New York State observational study was limited by its retrospective, cohort study design due to
possible unmeasured patient risk factors that may have been confounders impacting this study’s findings.
As one potential source of bias, TAVR was initially restricted by the FDA to high-risk patients. Based on
revisions in the TAVR eligibility criteria, TAVR was later made available to moderate-risk patients.

With mandatory submissions for all billed encounters enforced by Department of Health audits, this New
York statewide database is anticipated to be complete. Given these same billing codes were used in financial
transactions by these healthcare facilities with insurance agencies, this database’s findings are most likely
highly accurate. Although there is high confidence in the POAF/AFL propensity model, there was data
sparsity identified for the MM and READMIT multivariate logistic regression models; using appropriate
analytic techniques, however, these models also had relatively high c-indices with no calibration concerns
identified; hence, the POAF/AFL association reported with the READMIT endpoint appears to be robust
for this New York State-based r-AVR patient population. Although this study’s r-AVR population was
smaller in size, the SPARCS database represents the entire New York State population’s experience. Given
that r-AVR procedures occur infrequently, future investigations should use regional or national databases to
verify the generalizability of these New York State findings.

DECLARATIONS
Acknowledgements
Thanks are sent to the Stony Brook University Renaissance School of Medicine’s Department of Surgery
Division of Cardiothoracic Surgery staff (Ms. Kathleen O’Brien) and Scholarly Concentrations Programs
Research Track staff (Dr. Howard Fleit and Ms. Rhonda Kearns) for their administrative oversight and
support. Thanks are also sent to the Office of Quality and Patient Safety in the New York State Department
of Health for their SPARCS database access, support and guidance with this project. Finally, our team
acknowledges the biostatistical consultation and analytical support provided by the Biostatistical Consulting
Core (Dr. Jie Yang and Ms. Xiaoyue Zhang) at the Renaissance School of Medicine, Stony Brook University.