Page 19 - Read Online

Page 12 of 15 Tummala et al. Vessel Plus 2022;6:17 https://dx.doi.org/10.20517/2574-1209.2021.114

aortic stenosis, are also extremely detrimental, with a 5-year mortality rate of 50% and 10-year mortality of
90%. However, there is no data on mortality rates among untreated aortic stenosis patients with AF. More
importantly, SAVR and TAVR procedures without complications can curtail the progression of aortic
stenosis and improve the quality of life for many patients. However, a thorough examination of
comorbidities in patients with AF is beneficial prior to AVR, especially TAVR, given the high rates of
mortality which are comparable with untreated aortic stenosis.

In terms of POAF, it was more common after SAVR and in patients with old age, low body mass index, a
history of heart failure, hemodynamic instability, left atrial enlargement, and preoperative and early
postoperative left ventricular ejection fraction ≤ 50%. The rates for POAF following SAVR procedures have
been noted to range from 11.1% to 84%, while the rates for POAF following TAVR procedures range from
3.0% to 55.6%. Of note, POAF rates following TAVR were significantly greater in the transapical TAVR
subgroup (53%) in comparison to the transaortic TAVR subgroup (33%) and the transfemoral TAVR
subgroup (14%). Therefore, the risk of POAF can be lowered by choosing a transfemoral or transaortic
approach over a transapical approach. POAF can be prevented in high-risk patients via prophylactic
antiarrhythmic medications and atrial pacing for 24 h to several days. Prophylactic anticoagulants should
also be provided as they reduce the risk of thrombotic complications following SAVR and TAVR
procedures in the setting of POAF. These preventive measures are essential as POAF is associated with
higher mortality, cardiovascular events, a longer length of hospital stay, and an overall higher rate of
morbidity/mortality.

POAF after SAVR, in comparison to no AF development, is associated with increased stroke rates (8.5% vs.
0.0%) and longer hospital stays (9 days vs. 6 days). Given conflicting data, mortality may or may not be
higher among POAF patients, but 7-year mortality rates after SAVR are as high as 83% in non-AF and 78%
in POAF groups. Similarly, POAF after TAVR, compared to no AF development, is associated with
increased stroke rates (4.7% vs. 2.0% at 30 days and 7.2% vs. 3.8% at 1 year) and longer hospital stays (10.6
days vs. 6.3 days). POAF after TAVR is also associated with 1-year rehospitalizations (62.5% vs. 34.8%) and
major bleeding (31.7% vs. 23.0%). Notably, POAF after TAVR is associated with increased mortality rates
(7.8% vs. 3.4% at 30 days and 30.1% vs. 16.1% at 1 year). In both SAVR and TAVR, the development of
POAF seems to increase the risk of complications by around 1.5-fold, and prophylactic treatment should be
given in patients to prevent the development of POAF. Between the SAVR and TAVR procedures, TAVR
seems to be the preferred approach in terms of AF, given the lower risk of POAF development. However,
the risk of complications following AVR does not seem to improve expected survival compared to untreated
aortic stenosis drastically and should be prioritized in patients with severe aortic stenosis.

Limitations
While most articles referenced were specific to aortic valve replacement in aortic stenosis patients, a few
articles did not specifically limit studied patients to those with underlying aortic stenosis or aortic
regurgitation. In addition, the articles do not mention if the patients studied had concomitant mitral
regurgitation. Finally, the articles do not differentiate between bioprosthetic and mechanical/metallic valves;
however, the usage of mechanical valves in AVR has significantly decreased from 59.5% usage in 2008 to
29.2% usage in 2017 due to the rise in popularity of the bioprosthetic valve .
[65]

DECLARATIONS
Acknowledgments
Special thanks are provided to the Health Sciences Library (Ms. Jessica Koos) and the Scholarly
Concentration Program Research Track (Drs. Howard Fleit, Laurie Shroyer, and Ms. Rhonda Kearns) at the