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Tummala et al. Vessel Plus 2022;6:17 https://dx.doi.org/10.20517/2574-1209.2021.114 Page 11 of 15

receive anticoagulant therapy developed thromboembolism complications within 30 days, whereas only 3%
of TAVR patients with POAF who received anticoagulant treatments had similar complications.
Anticoagulation was also associated with lower rates of bioprosthetic valve dysfunction in the setting of
[59]
POAF after TAVR .

In terms of specific anticoagulant treatment, there is a lack of established consistency in clinical studies.
Some studies recommend the use of a combination of an oral anticoagulant like warfarin and an antiplatelet
drug such as aspirin or clopidogrel [26,60] . However, other studies have shown oral anticoagulant monotherapy
to be safe with a lower risk of major bleeding complications than a combined therapy of an oral
anticoagulant and an antiplatelet drug . In terms of oral anticoagulants used in TAVR patients with atrial
[61]
fibrillation, vitamin K antagonists seem to be the first-line choice . However, non-vitamin K oral
[30]
anticoagulants appear to be equally effective with lower intracranial hemorrhage, ischemic stroke, and
mortality rates than vitamin K antagonists [30,62] . An alternative to oral anticoagulation in TAVR patients with
atrial fibrillation is left atrial appendage occlusion. While relatively new, the surgical procedure has been
shown to be safe, effective, and associated with reduced bleeding compared to traditional anticoagulant
therapy [27,30] . In summary, there are various therapeutic approaches to prevent strokes in TAVR patients who
develop POAF.

Treatment and follow-up
Anticoagulation in the new-onset atrial fibrillation has been endorsed by the major cardiac societal
guidelines; however, it is still a topic of major debate among many physicians, especially regarding their
efficacy in real-life practice. The common practice is to treat it with rate and rhythm control medications.
[63]
Gillinov et al. found that 89.9% of POAF patients treated with rate-control therapy and 93.5% of patients
treated with rhythm-control therapy had a stable, sustained heart rhythm without AF at the time of
discharge (P = 0.14). More specifically, B-blockade and amiodarone have had the most conclusive studies
affirming their efficacy. Another drug that has recently emerged as a potential preventative option for post-
operative atrial fibrillation is colchicine .
[64]
It would also be optimal to have the patients under cardiac monitoring surveillance with continuous
electrocardiographic telemetry monitoring until hospital discharge. If an abnormal rhythm were to be noted
on the cardiac monitoring device, the medical team could manage it within an inpatient setting prior to
discharge to prevent future complications. Anticoagulation should be used with caution to prevent excess
bleeding .
[32]

CONCLUSION
Atrial fibrillation is associated with detrimental preoperative and postoperative outcomes regarding surgical
and transcatheter aortic valve replacement. Pre-existing atrial fibrillation has been seen in 6.3% to 35.2% of
SAVR patients and 15.7% to 48.9% of patients undergoing TAVR and has a higher prevalence in patients
with moderate to severe mitral regurgitation, moderate to severe tricuspid regurgitation, and pulmonary
hypertension.

Patients with pre-existing AF who undergo aortic valve replacement (AVR) have a greater risk of mortality
and major complications following the procedure than patients without AF. The risk of complications is
much greater in patients undergoing TAVR as SAVR has a 2-year mortality and major complication rate of
24.6%, while TAVR has a 1-year mortality rate of 34.9%, not even accounting for complications. The higher
prevalence of baseline comorbidities, including AF, among TAVR patients most likely explains the increase
in complications compared to SAVR. The risks of untreated aortic stenosis, especially severe symptomatic