Comparison of postprocedural new-onset atrial fibrillation between transcatheter and surgical aortic valve replacement: A systematic review and meta-analysis based on 16 randomized controlled trials

Background:Presently, transcatheter aortic valve replacement (TAVR) as an effective and convenient intervention has been adopted extensively for patients with severe aortic disease. However, after surgical aortic valve replacement (SAVR) and TAVR, the incidence of new-onset atrial fibrillation (NOAF) is prevalently found. This meta-analysis was designed to comprehensively compare the incidence of NOAF at different times after TAVR and SAVR for patients with severe aortic disease.Methods:A systematic search of PubMed, Embase, Cochrane Library, and Web of Science up to October 1, 2020 was conducted for relevant studies that comparing TAVR and SAVR in the treatment of severe aortic disease. The primary outcomes were the incidence of NOAF with early, midterm and long term follow-up. The secondary outcomes included permanent pacemaker (PM) implantation, myocardial infarction (MI), cardiogenic shock, as well as mortality and other complications. Two reviewers assessed trial quality and extracted the data independently. All statistical analyses were performed using the standard statistical procedures provided in Review Manager 5.2.Results:A total of 16 studies including 13,310 patients were identified. The pooled results indicated that, compared with SAVR, TAVR experienced a significantly lower incidence of 30-day/in-hospital, 1-year, 2-year, and 5-year NOAF, with pooled risk ratios (RRs) of 0.31 (95% confidence interval [CI] 0.23–0.41; 5725 pts), 0.30 (95% CI 0.24–0.39; 6321 pts), 0.48 (95% CI 0.38–0.61; 3441 pts), and 0.45 (95% CI 0.37–0.55; 2268 pts) respectively. In addition, TAVR showed lower incidence of MI (RR 0.62; 95% CI 0.40–0.97) and cardiogenic shock (RR 0.34; 95% CI 0.19–0.59), but higher incidence of permanent PM (RR 3.16; 95% CI 1.61–6.21) and major vascular complications (RR 2.22; 95% CI 1.14–4.32) at 30-day/in-hospital. At 1- and 2-year after procedure, compared with SAVR, TAVR experienced a significantly higher incidence of neurological events, transient ischemic attacks (TIA), permanent PM, and major vascular complications, respectively. At 5-year after procedure, compared with SAVR, TAVR experienced a significantly higher incidence of TIA and re-intervention respectively. There was no difference in 30-day, 1-year, 2-year, and 5-year all-cause or cardiovascular mortality as well as stroke between TAVR and SAVR.Conclusions:Our analysis showed that TAVR was superior to SAVR in decreasing the both short and long term postprocedural NOAF. TAVR was equal to SAVR in early, midterm and long term mortality. In addition, TAVR showed lower incidence of 30-day/in-hospital MI and cardiogenic shock after procedure. However, pooled results showed that TAVR was inferior to SAVR in reducing permanent pacemaker implantation, neurological events, TIA, major vascular complications, and re-intervention.     

Percutaneous aortic valve replacement for severe aortic regurgitation in degenerated bioprosthesis: the first valve in valve procedure using the Corevalve Revalving system.

Percutaneous valve replacement for severe aortic stenosis has shown to be an alternative treatment option for non-surgical candidates. We report on the first successful valve in valve procedure in an 80-year-old patient with a severe regurgitation of a degenerated aortic bioprosthesis using the Corevalve Revalving system.     

术前左心房最小容积对主动脉瓣狭窄术后症状的预测价值

目的 探讨术前左心房最小容积（LAVmin）对重度主动脉瓣狭窄（AS）患者外科主动脉瓣置换术(SAVR)后症状的预测能力。方法 本研究为前瞻性研究。入选2011年3月至2017年11月在福建医科大学附属漳州市医院行SAVR的AS患者84例,术前行超声心动图检查测量包括LAVmin指数（LAVmin经体表面积校正得到LAVImin）在内的相关参数,术后进行1年的随访,记录术后1个月至12个月之间出现的心力衰竭症状。根据术后心力衰竭症状有无,将患者分为两组：术后症状组（20例）,术后无症状组（64例）。用受试者工作特征（ROC）曲线评估超声心动图相关参数对术后症状的预测能力,采用多元Logistic回归分析评估术后症状的相关因素。结果 两组患者之间,术前左心室容积、左心室射血分数及左室舒张功能障碍程度均无明显差异。而术前LAVImin,在术后症状组和术后无症状组之间则存在显著差异[(45.1±11.6)ml/m2 比 (27.1±9.2)ml/m2,P＜0.01]。ROC曲线分析显示,当LAVImin ≥ 30.3 ml/m2时,ROC曲线下面积最大（0.84,敏感性94.1％,特异性69.6％）。在多元Logistic回归分析中,术前LAVImin是AS术后症状的独立预测因子（OR=2.17,95％CI 1.04～2.96,P=0.02)。结论 经超声心动图测得的术前LAVImin可作为AS患者SAVR术后症状的预测指标,术前LAVImin≥30.3 ml/m2有助于重度AS行SAVR手术时机的选择。     

Stroke event rates in anticoagulated patients with paroxysmal atrial fibrillation

Aims. To test the hypothesis that stroke and systemic embolic events (SEE) in the stroke prevention using an oral thrombin inhibitor in atrial fibrillation (SPORTIF) III and V trials are different between paroxysmal and persistent atrial fibrillation (AF). Methods. Data analysis from two cohorts of patients enroled in the prospective SPORTIF III and V clinical trials (n = 7329); 836 subjects (11.4%) with paroxysmal AF [mean age 70.1 years (SD = 9.5)] were compared with 6493 subjects with persistent AF for this ancillary study. Results. The annual event rates for stroke/SEE are 1.73% for persistent AF and 0.93% for paroxysmal AF. In a multivariate analysis, after adjusting for stroke risk factors, gender and aspirin usage, the differences remained statistically significant with a higher hazard ratio (HR) for stroke/SEE in persistent AF [vs. paroxysmal AF, HR 1.87, 95% confidence interval (CI) 1.04–3.36; P = 0.037]. In ‘high risk’ patients (with ≥2 stroke risk factors) annual event rates for stroke/SEE were 2.08% for persistent AF and 1.27% for paroxysmal AF (adjusted HR = 1.68, 95% CI 0.91–3.1, P = 0.098). Elderly patients had annual event rates for stroke/SEE of 2.38% for persistent AF and 1.13% for paroxysmal AF (adjusted HR = 2.27, 95% CI 0.92–5.59, P = 0.075). Vitamin K antagonist (VKA)‐naïve paroxysmal AF patients had a 1.89%/year stroke/SEE rate, compared with 0.61% for previous VKA takers (HR = 0.33, 95% CI 0.11–1.01, P = 0.052). Conclusion. In this large clinical trial cohort of anticoagulated AF patients, those with paroxysmal AF had stroke rates which were lower than for patients with persistent AF, although both groups had broadly similar stroke risk factors. Subjects with paroxysmal AF at ‘high risk’ had stroke/SEE rates that were not significantly different to persistent AF subjects.     

CHADS_2评分对心房颤动患者二尖瓣置换术围手术期脑卒中风险的预测作用

目的缺血性脑卒中是心脏手术后严重并发症,但其危险因素尚待进一步研究。本研究旨在探讨CHADS_2评分对二尖瓣置换术围手术期脑卒中风险的预测作用。方法选择2005年1月至2014年12月解放军总医院心血管外科行二尖瓣置换且术前合并房颤的患者共805例,年龄(53.7±10.5)岁,女性422例(52.4%)。观察不同CHADS_2评分患者二尖瓣置换术后住院期间缺血性脑卒中发生情况;比较CHADS_2评分≥2组和评分2组脑卒中发生率;采用多因素logistic回归分析方法对围手术期常见脑卒中危险因素进行分析,研究CHADS_2评分与术后脑卒中的关系。结果全组患者CHADS_2评分为0分者493例(61.2%),1分者185例(23.0%),2分者92例(11.4%),3分者26例(3.2%),4分者9例(1.1%)。术后住院期间发生缺血性脑卒中共14例,发生率为1.7%。住院期间死亡16例,死亡率2.0%。脑卒中发生于CHADS_2评分为0分者6例(发生率1.2%),1分者2例(发生率1.1%),2分者3例(发生率3.3%),3分者2例(发生率7.7%),4分者1例(发生率11.1%)。与CHADS_2评分2组比较,CHADS_2评分≥2组脑卒中发生率显著升高(4.7%vs 1.2%;P=0.005)。与低CHADS_2评分组比较,高CHADS_2评分组患者术前合并颈动脉狭窄、术中同期行CABG和植入机械瓣比例较高,术后机械通气时间更长(P0.05)。两组患者术后ICU停留时间以及住院期间病死率差异均无统计学意义(P0.05)。多因素logistic回归分析结果显示,CHADS_2评分≥2(OR=4.164,95%CI;1.388~12.495;P=0.011)和术后应用重组人凝血因子Ⅶa(OR=11.757,95%CI:2.909~47.520;P=0.001)是术后住院期间脑卒中的独立危险因素。结论 CHADS_2评分高的房颤患者二尖瓣置换术后住院期间脑卒中发生率更高,CHADS_2评分≥2是术后住院期间脑卒中的独立危险因素。CHADS_2评分对于预测房颤患者二尖瓣置换术围手术期脑卒中风险有一定价值,值得进一步研究。     

胺碘酮对心瓣膜置换术后阵发性心房颤动的疗效

目的 观察胺碘酮对心脏瓣膜置换术后病人心房颤动的临床疗效.方法 选择瓣膜置换术后心房颤动病人113例,其中胺碘酮组62例,非胺碘酮组51例,胺碘酮组给予胺碘酮0.15 g静脉注射后,以600μg/min持续静脉泵入,同时开始给予口服胺碘酮0.2 g,每日3次,7 d后改为0.2 g,每日2次,连用7 d后再改为0.2 g,每日1次维持.非胺碘酮组则给予强心苷或短效β-受体阻断药.比较术后10 d及术后3个月临床资料.结果 两组年龄、性别、术前心率、心脏复跳后窦性心律次数、心房颤动发作时心率、及术中阻断时间、体外循环时间、术后左心房大小差异无统计学意义.胺碘酮组术后10 d和3个月心房颤动转复和窦律维持比率分别为32/62和42/62,高于非胺碘酮治疗组6/51和4/51(P=0.000).结论 静脉及口服胺碘酮治疗心脏瓣膜置换术后心房颤动,有提高转复率和减少术后复发率作用.     

The impact of mitral stenosis on outcomes of aortic valve stenosis patient undergoing surgical aortic valve replacement or transcatheter aortic valve replacement

Background

The concomitant presence of mitral stenosis (MS) in the setting of symptomatic aortic stenosis represent a clinical challenge. Little is known regarding the outcome of mitral stenosis (MS) patients undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). Therefore, we sought to study the outcome of MS patients undergoing aortic valve replacement (AVR).

Method

Using weighted data from the National Inpatient Sample (NIS) database between 2011 and 2014, we identified patients who were diagnosed with MS. Patients who had undergone TAVR as a primary procedure were identified and compared to patients who had SAVR. Univariate and multivariate logistic regression analysis were performed for the outcomes of in‐hospital mortality, length of stay (LOS), blood transfusion, postprocedural hemorrhage, vascular, cardiac and respiratory complications, permanent pacemaker placement (PPM), postprocedural stroke, acute kidney injury (AKI), and discharge to an outside facility.

Results

A total of 4524 patients were diagnosed with MS, of which 552 (12.2%) had TAVR and 3972 (87.8%) had SAVR. TAVR patients were older (79.9 vs 70.0) with more females (67.4% vs 60.0%) and African American patients (7.7% vs 7.1%) (P < 0.001). In addition, the TAVR group had more comorbidities compared to SAVR in term of coronary artery disease (CAD), congestive heart failure (CHF), chronic lung disease, hypertension (HTN), chronic kidney disease (CKD), and peripheral vascular disease (PVD) (P < 0.001 for all). Using Multivariate logistic regression, and after adjusting for potential risk factors, TAVR patients had lower in‐hospital mortality (7.9% vs 8.1% adjusted Odds Ratio [aOR], 0.615; 95% confidence interval [CI], 0.392–0.964, P = 0.034), shorter LOS. Also, TAVR patients had lower rates of cardiac and respiratory complications, PPM, AKI, and discharge to an outside facility compared with the SAVR group.

Conclusion

In patients with severe aortic stenosis and concomitant mitral stenosis, TAVR is a safe and attractive option for patients undergoing AVR with less complications compared with SAVR.

     

胺碘酮在预防心脏瓣膜置换术后房颤中的作用

目的研究胺碘酮在预防心脏瓣膜置换术后高危患者房颤中的作用。方法常规体外循环下92例窦性心律、年龄〉50岁的瓣膜性心脏病择期行瓣膜置换术的患者,随机分为试验组（47例）和对照组（45例）。对照组术后给予常规药物和安慰剂。试验组除常规药物外,术后加用胺碘酮。两组比较瓣膜置换术后房颤的发生率。试验终点为术后第30天。结果瓣膜置换术后两组比较,试验组房颤发生率（8.5%）小于对照组（33.3%）,有统计学意义（P〈0.05）。结论胺碘酮能降低瓣膜置换术后高危患者房颤发生率,有效预防术后房颤的发生。     

瓣膜置换、房颤射频消融术治疗房颤的临床护理研究

目的：分析探讨瓣膜置换 房颤射频消融术治疗房颤患者的临床护理方法与效果。方法：选择我院2014年1月-2014年12月之间收治的行瓣膜置换 房颤射频消融术治疗的36例患者作为观察对象,采用随机的方式将其分为观察组和对照组各18例。对照组患者采取常规的护理干预;观察组患者应用系统护理方法。分析对比两组患者的临床治疗效果及患者满意度。结果：观察组患者术后出现并发症的比例小于对照组,差异具有统计学意义(P＜0.05);同时观察组患者对护理服务的满意度显著高于对照组,差异同样具有统计学意义(P＜0.05)。结论：对瓣膜置换 房颤射频消融术治疗房颤患者应用系统的护理干预具有很好的改善效果,构建和谐的护患关系,值得在临床中推广。     

Rhythm outcomes after aortic valve surgery: Treatment and evolution of new‐onset atrial fibrillation

BackgroundThe impact of new‐onset atrial fibrillation (AF) after aortic valve (AV) surgery on mid‐ and long‐term outcomes is under debate. Here, we sought to follow up heart rhythms after AV surgery, and to evaluate the mid‐term prognosis and effectiveness of treatment for patients with new‐onset AF.MethodsThis single‐center cohort study included 978 consecutive patients (median age, 59 years; male, 68.5%) who underwent surgical AV procedures between 2017 and 2018. All patients with postoperative new‐onset AF were treated with Class III antiarrhythmic drugs with or without electrical cardioversion (rhythm control). Status of survival, stroke, and rhythm outcomes were collected and compared between patients with and without new‐onset AF.ResultsNew‐onset AF was detected in 256 (26.2%) patients. For them, postoperative survival was comparable with those without new‐onset AF (1‐year: 96.1% vs. 99.3%; adjusted P = .30), but rate of stroke was significantly higher (1‐year: 4.0% vs. 2.2%; adjusted P = .020). With rhythm control management, the 3‐month and 1‐year rates of paroxysmal or persistent AF between patients with and without new‐onset AF were 5.1% versus 1.3% and 7.5% versus 2.1%, respectively (both P < .001). Multivariate models showed that advanced age, impaired ejection fraction, new‐onset AF and discontinuation of beta‐blockers were predictors of AF at 1 year.ConclusionsIn most cases, new‐onset AF after AV surgery could be effectively converted and suppressed by rhythm control therapy. Nevertheless, new‐onset AF predisposed patients to higher risks of stroke and AF within 1 year, for whom prophylactic procedures and continuous beta‐blockers could be beneficial.     

心房颤动患者经导管主动脉瓣植入术后1年随访结果

目的:探讨经导管主动脉瓣植入（TAVI）术前合并心房颤动（房颤）是否会对患者的预后产生影响。方法:本研究为单中心回顾性研究。入选2016年5月至2020年11月于北部战区总医院住院并成功接受TAVI治疗且顺利出院的重度主动脉瓣狭窄患者115例。根据入选患者是否合并房颤将其分为房颤组（21例）及非房颤组（94例）。随访纳...     

Effect of left atrial size and function on P-wave dispersion: a study in patients with paroxysmal atrial fibrillation

BACKGROUND: Paroxysmal atrial fibrillation (PAF), a common arrhythmia, is caused by the fractionated and nonhomogeneous propagation of sinus impulse. HYPOTHESIS: This study was undertaken to examine the effect of left atrial (LA) dimension and function on P-wave dispersion (deltaP) in unselected patients with PAF and health controls. METHOD: In this study, 62 consecutive patients with PAF (32 men, 30 women, mean age 55+/-11 years) and 62 age- and gender-matched healthy controls (33 men, 29 women, mean age 52+/-13 years) were studied to compare the effect of LA size, volume, and function on deltaP (difference between maximum and minimum P-wave duration on 12-lead electrocardiogram). RESULTS: P-wave dispersion in patients with PAF and normal LA diastolic diameter (LAD) was longer than that in controls with normal LA size (53+/-8 vs. 34+/-8 ms, p < 0.001). P-wave dispersion increased in patients with PAF (62+/-12 vs. 53+/-8 ms, p = 0.003) and controls (40+/-7 vs. 34+/-8 ms, p = 0.005) with increased LAD. Presence or absence of PAF did not interact with LAD for their effect on deltaP (2 x 2 analysis of variance test p = 0.20). In the PAF group, deltaP correlated with LAD (r = 0.43, p = 0.002), LA diastolic volume (r = 0.6, p < 0.001), and LA ejection fraction (AEF) (r = - 0.33, p = 0.05). The AEF was preserved when LAD increased in the patients without PAF (0.52+/-0.07 vs. 0.57+/-0.10, p = NS), however was significantly decreased in the PAF group (0.37+/-0.12 vs. 0.49+/-0.10, p = 0.01). On multivariate logistic regression analysis, only deltaP retained significance on development of PAF. CONCLUSION: It was concluded that deltaP increased in patients with PAF and normal LA size. In controls with increased LA size, deltaP increased but did not reach the levels attained in patients with PAF. The AEF was decreased in patients with PAF but was preserved in those without PAF. These findings can be explained by the changes in LA microarchitecture which concurrently decreased atrial myocardial contraction, increased deltaP, and predisposed to PAF.     

Clinical and prognostic implications of atrial fibrillation in patients undergoing transcatheter aortic valve implantation

AIM: To study a cohort of consecutive patients under-going transcatheter aortic valve implantation (TAVI) and compare the outcomes of atrial fibrillation (AF) patients vs patients in sinus rhythm (SR). METHODS: All consecutive patients undergoing TAVI in our hospital were included. The AF group comprised patients in AF at the time of TAVI or with history of AF, and were compared with the SR group. Procedural, echocardiographic and follow-up variables were compared. Likewise, the CHA 2 DS 2-VASC stroke risk score and HAS-BLED bleeding risk score and antithrombotic treatment at discharge in AF patients were compared with that in SR patients. RESULTS: From a total of 34 patients undergoing TAVI, 17 (50%) were allocated to the AF group, of whom 15 (88%) were under chronic oral anticoagulation. Patients in the AF group were similar to those in the SR group except for a trend (P = 0.07) for a higher logistic EuroSCORE (28% vs 19%), and a higher prevalence of hypertension (82% vs 53%) and chronic renal failure (17% vs 0%). Risk of both stroke and bleeding was high in the AF group (mean CHA 2 DS 2-VASC 4.3, mean HAS-BLED 2.9). In the AF group, treatment at discharge included chronic oral anticoagulation in all except one case, and in association with an antiplatelet drug in 57% of patients. During a mean follow-up of 11 mo (maximum 32), there were only two strokes, none of them during the peri-procedural period: one in the AF group at 30 mo and one in the SR group at 3 mo. There were no statistical differences in procedural success, and clinical outcome (survival at 1 year 81% vs 74% in AF and SR groups, respectively, P = NS). CONCLUSION: Patients in AF undergoing TAVI show a trend to a higher surgical risk. However, in our cohort, patients in AF did not have a higher stroke rate compared to the SR group, and the prognosis was similar in both groups.