Postprocedural Atrial Fibrillation After Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement

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1 ADULT CARDIAC Postprocedural Atrial Fibrillation After Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement Lukas J. Motloch, MD,* Sara Reda, MD,* Dennis Rottlaender, MD, Rosa Khatib, Jochen Müller-Ehmsen, MD, Catherine Seck, MD, Justus Strauch, MD, Navid Madershahian, MD, Erland Erdmann, MD, Thorsten Wahlers, MD, and Uta C. Hoppe, MD Department of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria; Department of Cardiothoracic Surgery, University of Bochum, Bochum, Germany; and Departments of Internal Medicine III and Cardiothoracic Surgery, and Center of Molecular Medicine Cologne, University of Cologne, Cologne, Germany Background. Transcatheter aortic valve implantation (TAVI) represents an alternative option for elderly patients with severe aortic valve stenosis who are denied surgical aortic valve replacement (SAVR) because of high perioperative risk. The impact of TAVI on postprocedural atrial fibrillation is undefined. Methods. In a single-center analysis, we assessed clinical data, preoperative risk scores (Society for Thoracic Surgeons score, logistic European System for Cardiac Operative Risk Evaluation), preprocedural electrocardiograms, and 72-hour postprocedural rhythm monitoring of 170 patients undergoing TAVI (n 84) or SAVR (n 86). In a subanalysis, transapical (n 43) and transfemoral TAVI (n 41) were compared. Results. Expectedly, TAVI patients were significantly older, presented with more severe symptoms, had higher Society for Thoracic Surgeons score, higher logistic European System for Cardiac Operative Risk Evaluation score, and revealed more frequently intermittent atrial fibrillation compared with SAVR patients. Despite this more compromised health state, prevalence of postprocedural atrial fibrillation was significantly lower in the TAVI group (6.0%, versus 33.7% after SAVR, p < 0.05). More than two thirds of TAVI patients but no SAVR patient with atrial fibrillation in preprocedural electrocardiograms had stable sinus rhythm during 72-hour postprocedural monitoring. Notably, no atrial fibrillation was observed after transfemoral TAVI. Whereas atrial fibrillation onset in the SAVR group predominantly occurred on postoperative day 3, atrial fibrillation onset after transapical TAVI was obtained within the first 24 hours after the intervention. Conclusions. Our results indicate that TAVI, compared with SAVR, reduces the risk of periprocedural atrial fibrillation. Furthermore, preprocedural atrial fibrillation may be converted into sinus rhythm particularly after transfemoral TAVI, suggesting an impact of decreased intracardiac pressures in the absence of adverse periprocedural factors that might promote atrial fibrillation. (Ann Thorac Surg 2012;93:124 32) 2012 by The Society of Thoracic Surgeons Aortic valve replacement is a class I indication for the treatment of severe symptomatic aortic valve stenosis [1]. Postoperatively, atrial arrhythmias develops in as many as half of all patients undergoing surgical aortic valve replacement (SAVR), with atrial fibrillation (AF) being the most common form [2 4]. Onset of AF after cardiac surgery typically occurs on the second or third postoperative day and is associated with increased inhospital mortality, a higher incidence of stroke, and a prolonged hospital stay [4]. Furthermore, AF was identified as a predictor of long-term mortality in patients undergoing cardiac surgery [3, 5]. Increasing patients Accepted for publication Aug 30, *Drs Motloch and Reda contributed equally to this work. Address correspondence to Dr Hoppe, Department of Internal Medicine II, Paracelsus Medical University Salzburg, Muellner Hauptstr 48, Salzburg A-5020, Austria; u.hoppe@salk.at. age is an independent risk factor for the development of postoperative atrial arrhythmias [2]. Elderly patients with severe symptomatic aortic valve stenosis frequently are denied cardiac surgery owing to a high perioperative risk [6, 7]. In recent years, transcatheter aortic valve implantation (TAVI) has emerged as an alternative technique to SAVR in these patients [8]. Transcatheter aortic valve implantation improved long-term survival compared with conservative management in patients considered at high or prohibitive surgical risk [9]. Moreover, TAVI may be performed by a transcatheter approach through the femoral arteries (transfemoral aortic valve implantation) [10] or through a left anterolateral minithoracotomy (transapical aortic valve implantation) [11]. The periprocedural risk for AF in patients undergoing TAVI has not yet been analyzed systematically. Thus, the aim of this study was to evaluate the incidence, onset, duration, and type of periinterventional AF in TAVI patients in compari by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc doi: /j.athoracsur

2 Ann Thorac Surg MOTLOCH ET AL 2012;93: ATRIAL FIBRILLATION AFTER TAVI son with patients who received SAVR. A subanalysis was performed to assess potential differences in the characteristics of periprocedural AF in patients undergoing a transfemoral versus transapical approach. Material and Methods Study Participants The study was performed in compliance with the Helsinki declaration and was approved by the Institutional Review Board. No patient consent was required for inclusion in this retrospective analysis. The study cohort comprised 84 consecutive patients with severe symptomatic aortic valve stenosis who underwent TAVI between November 1, 2009, and December 31, For comparison, a similar number of consecutive patients who underwent SAVR with a stented bioprosthesis during the same time were analyzed. In all patients, The Society of Thoracic Surgeons (STS) score and logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) were calculated [12 15]. Information about the clinical severity (New York Heart Association functional class), medication, concomitant diseases, and laboratory measurements was obtained from the university patient database. Furthermore, echocardiographic records and electrocardiographic recordings were analyzed. Patients were divided into two groups: TAVI and SAVR. Given the distinct interventional approach, subgroup analysis was performed for transapical and transfemoral TAVI. Aortic Valve Implantation and Replacement The SAVR was performed using a standard midline sternotomy, cardiopulmonary bypass, and mild hypothermia. All patients received a stented bioprosthesis. The size of the prosthesis was selected according to the size of the aortic annulus, as determined by the manufacturer s sizer. The TAVI procedure is approved for compassionate clinical use by the European Association of Cardiothoracic Surgery and the European Society of Cardiology for patients with severe symptomatic aortic stenosis considered either inoperable or at very high risk for a surgical procedure [8]. Based on these recommendations, patients were evaluated and offered TAVI by a board of cardiologists and cardiothoracic surgeons [8]. The TAVI was performed using the Edwards Sapien (Edwards Lifesciences, Irvine, CA) balloon-expandable prosthesis with two available valve sizes (expanded diameters 23 mm and 26 mm) by the transfemoral or transapical approach using techniques, as previously described [10, 11]. Patients aortic annulus diameter was estimated by transesophageal echocardiography. The 23-mm valves were selected for aortic annuluses between 16 mm and 21 mm, and the 26-mm valves were selected for aortic annuluses between 22 and 25 mm. 125 SAVR (0.8%) or TAVI (5.8%) were excluded from this analysis. Further exclusion criteria included additional coronary artery bypass graft surgery, aortic root enlargement, the Bentall procedure, or additional replacement of other valves. Definition of Preexisting AF Atrial fibrillation was defined as the presence of an irregular rhythm with fibrillatory waves and no defined P waves in the electrocardiogram (ECG) [16]. Patients ECG recordings and data were analyzed for the presence of AF and a history of AF, respectively. Preexisting AF was defined as the presence of AF in an ECG obtained 24 hours before the procedure or as indicated by a diagnosis found in the medical records, the hospital s database, or the outpatient department s database. Preexisting AF was classified into paroxysmal, persistent, or permanent AF according to the international guidelines [17]. Preprocedural Rhythm Monitoring Twelve-lead ECGs were recorded 24 hours before the procedure. Electrocardiograms were analyzed for rhythm, presence of bundle branch block (except for pacemaker rhythm), and axis deviation (except for pacemaker rhythm, right or left bundle branch block). Definition and Monitoring of Postprocedural AF Rhythm was monitored continuously by bedside electronic monitors. We analyzed the ECG monitoring for incidence and duration of AF in a period of 72 hours after the procedure. Postprocedural AF was defined as at least one episode of AF lasting more than 10 minutes [3]. For the first postprocedural AF episode, heart rate was evaluated: tachyarrhythmic AF was defined as an ECG episode of AF with a heart rate greater than 100 beats per minute; bradyarrhythmic AF was diagnosed when heart rate of AF was less than 40 beats per minute; and normofrequent AF was specified as a heart rate of 40 to 100 beats per minute. Laboratory Measurements Blood samples were drawn 24 hours before and after the procedure. Blood samples were analyzed for electrolytes, kidney retention parameters, blood count, and C-reactive protein. Echocardiography Transthoracic echocardiography was performed at baseline and before hospital discharge by experienced investigators. Echocardiography was analyzed for preprocedural left ventricular ejection fraction, calculated with the Simpson method. Transvalvular pressure gradients determined by the Bernoulli formula and aortic valve area estimated by the continuity equation were obtained before and after the procedure. ADULT CARDIAC Exclusion Criteria Patients with permanent AF (ie, AF lasting longer than 6 months or documented unsuccessful cardioversion), postprocedural sepsis, or death within 72 hours after Statistical Analysis Statistical analyses were performed using PASW statistics 18 software (SPSS, Chicago, IL). All variables were tested for normal distribution with the Kolmogorov-

3 ADULT CARDIAC 126 MOTLOCH ET AL Ann Thorac Surg ATRIAL FIBRILLATION AFTER TAVI 2012;93: Table 1. Patient Characteristics SAVR (n 86) TAVI (n 84) Characteristic n % or Mean SEM n % or Mean SEM Age a Male STS score For mortality (%) a For morbidity (%) a Logistic EuroSCORE a Disease-related symptoms Syncope Previous cardiac decompensation b Dyspnea, NYHA class II c III c IV c History of intermittent AF b Paroxysmal AF b Persistent AF b Medical history Hypertension Coronary artery disease Myocardial infarction Coronary artery bypass grafts b Stroke or transient ischemic attack Peripheral vascular occlusive disease Diabetes mellitus Chronic obstructive lung disease Pulmonary hypertension Medication Beta-blockers Digitalis Amiodarone Diuretics ACE inhibitor/arb a p less than 0.05 SAVR versus TAVI (Student t test). b p less than 0.05 SAVR versus TAVI ( 2 testing). c p less than 0.05 SAVR versus TAVI (Mann-Whitney U test). ACE angiotensin-converting enzyme; AF atrial fibrillation; ARB angiotensin-receptor blocker; EuroSCORE European System for Cardiac Operative Risk Evaluation; NYHA New York Heart Association; SAVR surgical aortic valve replacement; SEM standard error of mean; STS The Society of Thoracic Surgeons; TAVI transcatheter aortic valve implantation. Smirnov test. Results are given as mean SEM. Differences between groups were evaluated by 2 testing for discrete variables and Student t test for continuous variables. For ordinal data, the Mann-Whitney U test was used. A p value less than 0.05 was considered as statistically significant. Results Baseline Characteristics In all, 170 patients treated for severe symptomatic aortic valve stenosis were analyzed. Eighty-four patients underwent TAVI and 86 underwent SAVR. The demographic variables of the groups are shown in Table 1. Expectedly, TAVI patients were older, had significantly higher STS scores, higher logistic Euro- SCOREs, and exhibited more severe disease-related symptoms (significantly higher New York Heart Association class and incidence of previous cardiac decompensations). Consistent with this more compromised health state, TAVI patients more often presented with renal impairment as evident by a lower mean estimated glomerular filtration rate (Table 2). While the prevalence of prior coronary artery bypass graft surgery was significantly higher in the TAVI group, other comorbidities and baseline medication did not differ significantly compared with SAVR patients (Table 1). Preprocedural echocardiography revealed a comparable left ventricular function and similar severity of transvalvular pressure gradients and estimated aortic

4 Ann Thorac Surg MOTLOCH ET AL 2012;93: ATRIAL FIBRILLATION AFTER TAVI Table 2. Periprocedural Laboratory Measurements SAVR (n 86) TAVI (n 84) Laboratory Parameters Mean SEM Mean SEM Preprocedural Potassium, mmol/l egfr, ml/min a CRP, mg/l Leukocytes, e9/l Hemoglobin, g/dl Postprocedural Potassium, mmol/l egfr, ml/min CRP, mg/l Leukocytes, e9/l Hemoglobin, g/dl a p less than 0.05 SAVR versus TAVI (Student t test). CRP C-reactive protein; egfr estimated glomerular filtration rate; SAVR surgical aortic valve replacement; SEM standard error of mean; TAVI transcatheter aortic valve implantation. valve areas in patients who underwent TAVI and SAVR, respectively (Table 3). Notably, patients treated by TAVI had a significantly higher prevalence of intermittent (paroxysmal or persistent) AF versus the SAVR group, both in their history (32.1% versus 12.8%, p 0.05; Table 1) and baseline ECG recordings (11.9% versus 5.8%, p 0.05; Fig 1A, Table 4). We did not obtain any preprocedural differences in heart rate, prevalence of bundle brunch block, or axis deviation between groups (Table 4). There was no difference in the rate of complications during the 72-hour monitoring phase (Table 5). Postprocedural AF The transvalvular aortic pressure gradients ( P mean and P max ) significantly and comparably decreased after TAVI and SAVR, respectively, while the aortic valve area increased (Table 3), confirming successful treatment of aortic valve stenosis. Notably, the prevalence of postprocedural AF was significantly lower after TAVI compared with SAVR (6.0% versus 33.7%, p 0.05), despite a higher preimplantation prevalence of AF in the TAVI group (Fig 1A, Table 4). The distribution of the heart rate during the first postprocedural AF episode obtained was similar in both groups (Fig 1B). There were no differences in postprocedural laboratory parameters, particularly potassium serum levels that could have accounted for the observed effect (Table 2). Because AF is known to occur intermittently, in patients with postprocedural AF, the number of episodes was counted, and the duration of the longest episode was measured. The TAVI patients with AF presented a maximum of two episodes and tended to have shorter AF duration compared with the SAVR group (Table 4). Consistent with previous reports, in the SAVR group episodes of postoperative AF occurred during the whole period of rhythm monitoring, with the highest prevalence on postoperative day 3 (Fig 1C) [4]. In contrast, all episodes of AF in the TAVI group occurred within the first 24 hours after the intervention. Periprocedural New-Onset AF and Cardioversion of Preexisting AF The different susceptibility for AF between TAVI and SAVR patients became even more evident when analyzing only patients without preexisting AF. In this subgroup, the incidence of new-onset AF was 3.5% in patients after TAVI versus 30.7% after SAVR (p 0.05; Fig 1D), indicating a markedly lower risk of AF induction by TAVI compared with conventional open heart surgery [4]. In the ECG recorded 24 hours before the intervention, 11.9% of patients in the TAVI group had documented AF. Eight of these 10 patients had a positive history of persistent AF. Notably, 7 of the 10 patients with documented AF and 6 of those with persistent AF were in sinus rhythm throughout the 72-hour monitoring period after TAVI. The patients who remained in AF were treated with the transapical approach. Conversely, in the SAVR group, 5.8% of patients showed AF in preoperative ECGs, with no patient converting to sinus rhythm perioperatively. Comparison of Transfemoral Versus Transapical TAVI Based on the interventional technique, the TAVI group was subdivided into 41 patients receiving a transfemoral approach and 43 patients receiving a transapical approach. We did not observe significant differences in demographic variables, STS score, or logistic EuroSCORE between subgroups (Table 6). In both subgroups, the transvalvular aortic pressure gradients ( P mean and P max ) significantly decreased, and the aortic valve area increased after TAVI (Table 6), indicating success of the intervention. Patients treated by transfemoral TAVI had a higher prevalence of preexisting AF in their history, whereas the transapical group tended to have more frequently AF in preprocedural ECGs, although these differences did not reach statistical significance (Table 6). Table 3. Periprocedural Echocardiographic Studies SAVR (n 86) TAVI (n 84) Echocardiographic Parameters Mean SEM Mean SEM Preprocedural TTE P max,mmhg P mean,mmhg Aortic valve area, cm LVEF, % Postprocedural TTE P max,mmhg P mean,mmhg Aortic valve area, cm LVEF left ventricular ejection fraction; P max maximal transaortic pressure gradient; P mean mean transaortic pressure gradient; SAVR surgical aortic valve replacement; SEM standard error of mean; TAVI transcatheter aortic valve implantation; TTE transthoracic echocardiography. ADULT CARDIAC

5 ADULT CARDIAC 128 MOTLOCH ET AL Ann Thorac Surg ATRIAL FIBRILLATION AFTER TAVI 2012;93: Fig 1. Atrial fibrillation (AF) in patients undergoing surgical aortic valve replacement (SAVR [black bars]) or transcatheter aortic valve implantation (TAVI [white bars]). (A) Prevalence of AF before and after the procedure. Preprocedural rhythm was determined by 12-lead electrocardiogram 24 hours before the procedure. Postprocedural rhythm was monitored by continuous bedside electronic monitors for 72 hours. (B) Heart rate of the first postprocedural AF episode. Tachyarrhythmic AF (TAF [black areas]) was defined as an electrocardiographic diagnosis of AF with a heart rate greater than 100 beats per minute; bradyarrhythmic AF (BAF [white areas]) was diagnosed when heart rate was less than 40 beats per minute; and normofrequent AF (NAF [gray areas]) was specified as a heart rate within a range of 40 to 100 beats per minute. (C) Timing of new-onset of postprocedural AF. In the TAVI group (white bars), AF occurred only on postinterventional day 1 (black bars SAVR group). (D) Incidence of new-onset AF after SAVR (black bar) or TAVI (white bar), respectively, in patients without evidence of preexisting AF. In the TAVI group, postinterventional AF was only observed in patients treated by a transapical approach. *p less than 0.05 SAVR versus TAVI. Postoperative AF appeared in 11.6% of patients who underwent transapical TAVI. Notably, postinterventional AF was not observed in any patient treated by transfemoral TAVI (p 0.05 versus transapical TAVI). The 4 patients with AF in the preprocedural ECG had spontaneous periinterventional conversion into sinus rhythm after transfemoral TAVI. These results suggest that the transfemoral approach might be more protective against induction of AF than the transapical approach. Comment In the present study, we analyzed the incidence and characteristics of postprocedural AF in an elderly cohort with severe symptomatic aortic valve stenosis either treated conventionally with open heart surgery and implantation of a bioprosthesis (SAVR) or minimally invasively by transfemoral or transapical TAVI. For the treatment of severe symptomatic aortic valve stenosis, SAVR represents the gold standard [1]. Consistent with international recommendations, patients who underwent TAVI in the present study were older and considerably sicker than SAVR patients [1, 8]. Notably, that included characteristics known to predispose to postoperative AF after open heart surgery, namely, previous congestive heart failure, impaired renal function, and increased patients age [2, 4]. Moreover, TAVI patients had a significantly higher rate of AF documented in preprocedural ECGs or a positive history of previous AF. Based on these baseline risk factors, an increased prevalence of postprocedural AF might have been expected in TAVI patients. However, in contrast, AF occurred significantly less often after TAVI than after SAVR, indicating a lower periprocedural risk for AF induction during TAVI. Consistently, among patients without a history of any AF, the rate of new-onset AF was markedly lower after TAVI compared with SAVR. Additionally, more than two thirds of TAVI patients but no SAVR patient with AF in the preprocedural ECG had a stable sinus rhythm during the 72-hour monitoring period after aortic valve implantation. Previous studies demonstrated a significant reduction of left atrial pressure in the first postoperative days after aortic valve replacement for aortic stenosis [18, 19]. Given that increased left atrial pressure may trigger AF [20 22], a decrease of the intracardiac pressure likely accounted for stabilization of sinus rhythm after TAVI, whereas the more favorable intracardiac hemodynamics after SAVR seem to have been offset

6 Ann Thorac Surg MOTLOCH ET AL ;93: ATRIAL FIBRILLATION AFTER TAVI Table 4. Periprocedural Rhythm Monitoring SAVR (n 86) TAVI (n 84) ECG Parameters n % or Mean SEM n % or Mean SEM ADULT CARDIAC Preprocedural 12-lead ECG Intermittent AF a Heart rate, beats per minute Normal deviation Left deviation Right deviation RBB LBB LAHB Bifascicular block Postprocedural 72-hour ECG bedside monitoring = Intermittent AF a Mean duration longest episode, minutes 29 1, Number of episodes, percent of AF patients a p less than 0.05 SAVR versus TAVI ( 2 test). AF atrial fibrillation; ECG electrocardiogram; LAHB left anterior bundle branch block; LBB left bundle branch block; RBB right bundle branch block; SAVR surgical aortic valve replacement; SEM standard error of mean; TAVI transcatheter aortic valve implantation. Table 5. Major Complications Within 72 Hours After Intervention SAVR (n 86) TAVI (n 84) Outcome n % n % Stroke or transient ischemic attack Either Transient ischemic attack Stroke Vascular complication Any Major Major bleeding Acute kidney injury Creatinine 3 mg/dl, renal failure Renal replacement therapy New pacemaker Pericardial effusion SAVR surgical aortic valve replacement; aortic valve implantation. TAVI transcatheter by adverse factors associated with open-heart surgery such as aortic cross-clamping and cardiopulmonary bypass [2]. In a subgroup analysis, we further compared the occurrence of postprocedural AF among patients treated by transfemoral versus transapical TAVI. No difference in baseline patients characteristics was obvious. Postprocedural AF was only observed after transapical TAVI, and thus was significantly less frequent after the transfemoral approach than after the transapical approach. Indeed, despite a positive AF history of 36.6% and documented AF in 9.8% preprocedurally, no case of postinterventional AF was detected in the transfemoral TAVI group, further underscoring the beneficial effect of intracardiac pressure relief. Moreover, these data support the notion that the transfemoral TAVI procedure in itself is not associated with an increased risk of AF induction and might be the most sinus rhythm conserving approach. Given previous reports describing a peak of postoperative AF on days 2 and 3 after cardiac surgery [4], we chose 72 hours of postprocedural rhythm monitoring in the present study. Consistent with these previous observations, in the SAVR cohort, most episodes of AF were detected on day 3 of the postoperative course. Conversely, in patients who underwent TAVI, AF onset was only observed on the first postinterventional day. Although we can not entirely exclude a delayed onset of AF beyond postprocedural day 3, these data suggest that rhythm monitoring of patients undergoing TAVI is particularly important during the early postprocedural phase to prevent any potential hemodynamic deterioration. In conclusion, our results indicate that, in comparison with SAVR, TAVI reduces the risk of periprocedural AF. Furthermore, preprocedural AF may be converted into sinus rhythm particularly after transfemoral TAVI, suggesting an impact of decreased intracardiac pressures

7 ADULT CARDIAC 130 MOTLOCH ET AL Ann Thorac Surg ATRIAL FIBRILLATION AFTER TAVI 2012;93: Table 6. Characteristics of TAVI Patients Transapical TAVI (n 43) Transfemoral TAVI (n 41) Characteristics n % or Mean SEM n % or Mean SEM Age Male STS score For mortality, % For morbidity, % Logistic EuroSCORE Disease-related symptoms Syncope Previous cardiac decompensation Dyspnea, NYHA class II III/IV Medical history Hypertension Coronary artery disease Myocardial infarction Coronary artery bypass grafts Stroke or transient ischemic attack Peripheral vascular occlusive disease Diabetes mellitus Chronic obstructive lung disease Pulmonary hypertension Preprocedural TTE P max,mmhg P mean,mmhg Aortic valve area, cm LVEF, % Postprocedural TTE P max,mmhg P mean,mmhg Aortic valve area, cm Atrial fibrillation History of intermittent AF Preprocedural AF on 12-lead ECG Postprocedural AF a a p less than 0.05 transapical TAVI versus transfemoral TAVI. AF atrial fibrillation; P max maximal transaortic pressure gradient; P mean mean transaortic pressure gradient; ECG electrocardiogram; EuroSCORE European System for Cardiac Operative Risk Evaluation; LVEF left ventricular ejection fraction; NYHA New York Heart Association; SEM standard error of mean; STS The Society of Thoracic Surgeons; TAVI transcatheter aortic valve implantation; TTE transthoracic echocardiography. without adverse periprocedural factors that might promote AF. Whether these beneficial effects on postprocedural rhythm translate into improved short-term and long-term morbidity and mortality of TAVI patients compared with SAVR patients will have to be determined in randomized trials. References 1. Bonow RO, Carabello BA, Kanu C, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. Circulation 2006;114:e Creswell LL, Schuessler RB, Rosenbloom M, et al. Hazards of postoperative atrial arrhythmias. Ann Thorac Surg 1993; 56: Filardo G, Hamilton C, Hamman B, et al. New-onset postoperative atrial fibrillation and long-term survival after aortic valve replacement surgery. Ann Thorac Surg 2010;90: Maisel WH, Rawn JD, Stevenson WG. Atrial fibrillation after cardiac surgery. Ann Intern Med 2001;135: Villareal RP, Hariharan R, Liu BC, et al. Postoperative atrial fibrillation and mortality after coronary artery bypass surgery. J Am Coll Cardiol 2004;43:742 8.

8 Ann Thorac Surg STEFANO BENUSSI ET AL 2012;93: ATRIAL FIBRILLATION AFTER TAVI 6. Iung B, Baron G, Butchart EG, et al. A prospective survey of patients with valvular heart disease in Europe: the Euro heart survey on valvular heart disease. Eur Heart J 2003;24: Iung B, Cachier A, Baron G, et al. Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery? Eur Heart J 2005;26: Vahanian A, Alfieri O, Al-Attar N, et al. Transcatheter valve implantation for patients with aortic stenosis: a position statement from the European Association of Cardio- Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2008;29: Leon MB, Smith CR, Mack M, et al. Transcatheter aorticvalve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010;363: Webb JG, Pasupati S, Humphries K, et al. 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Pacing Clin Electrophysiol 1995;18: Yoshida K, Ulfarsson M, Oral H, et al. Left atrial pressure and dominant frequency of atrial fibrillation in humans. Heart Rhythm 2010;8: ADULT CARDIAC INVITED COMMENTARY Although not a surprise for a number of reasons, Motloch and colleagues [1] finding of an abated risk of periprocedural atrial fibrillation (AF) after transarterial aortic valve implantation (TAVI) is an interesting confirmation. In fact, even though the risk that new AF episodes will develop is much higher after conventional open aortic valve replacement (AVR), recently published evidence shows that central nervous system embolic complications appear to occur much more frequently after endovascular procedures. This evidence might further support the assumption that cerebrovascular events after TAVI are not related to arrhythmia but rather to embolization of atherosclerotic lesions of the aorta and its major branches. In Motloch and colleagues [1] study, cerebrovascular events and major vascular complications were documented basically only in TAVI patients, whereas major bleeding and acute kidney injury were prevalent in the surgical AVR group, pointing out that the procedural risks are qualitatively different but at least balanced between the two strategies. To better ascertain the effect of the overall different risk profiles of the two approaches, it would have been interesting if the authors had evaluated the in-hospital length of stay in the two groups, which is finally a critical issue, especially in elderly patients. Many studies are comparing TAVI with surgical AVR in complications, and in some cases, there is not a strong evidence of a superiority of TAVI, in particular considering vascular complications and embolism in general. Their article strongly supports the superiority of the TAVI procedure compared with surgical AVR, adding evidence to that already accumulated by the noninferiority study, Placement of Aortic Transcatheter Valves trial (PARTNER) cohort A. It is quite agreeable that TAVI is today already preferable in a growing proportion of elderly and fragile patients. New technology will very probably make it worthwhile in a larger proportion of clinical situations. By definition, TAVI allows avoiding most of the factors causing AF after standard open AVR, such as the inflammatory effect of cardiopulmonary bypass and cardioplegic arrest, part of the postoperative increase of adrenergic tone and pericarditis. Therefore, the fact that TAVI patients experience less periprocedural AF than those receiving AVR is not unexpected. As confirmed by Motloch and colleagues results, TAVI also reduces the risk of renal failure. But do these patients have a lower stroke risk? Do they really survive better and longer after treatment? We do not know yet. We know that AVR treats quite consistently the disease and is still considered the standard treatment for most patients. TAVI is newer and definitely less traumatic, but early and late results are both being defined. It is a different treatment. Less trauma does not always mean better treatment, otherwise we would still be treating aortic valve stenosis with medical treatment or with balloon valvuloplasty by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc doi: /j.athoracsur