Download PDF
Thromb Haemost 2020; 120(11): 1580-1586
DOI: 10.1055/s-0040-1715833
Stroke, Systemic or Venous Thromboembolism

Bleeding Complications Drive In-Hospital Mortality of Patients with Atrial Fibrillation after Transcatheter Aortic Valve Replacement

Achim Lother
1   Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
2   Institute of Experimental and Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
,
Klaus Kaier
1   Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
3   Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
,
Ingo Ahrens
1   Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
4   Augustinerinnen Hospital, Academic Teaching Hospital, University of Cologne, Cologne, Germany
,
Wolfgang Bothe
5   Department of Cardiac and Vascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
,
Dennis Wolf
1   Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
,
Manfred Zehender
1   Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
,
Christoph Bode
1   Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
,
Constantin von zur Mühlen   *
1   Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
,
Peter Stachon   *
1   Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
› Author Affiliations Funding A.L. is funded by the Berta-Ottenstein-Program for Advanced Clinician Scientists, Faculty of Medicine, University of Freiburg.
› Further Information
    Permissions and Reprints

Letter to:

Transcatheter Aortic Valve Implantation, Atrial Fibrillation, and Bleeding: A Surprisingly Fatal AttractionThromb Haemost 2020; 120(11): 1479-1482
DOI: 10.1055/s-0040-1718533

Abstract

Background Atrial fibrillation (AF) is a risk factor for poor postoperative outcome after transfemoral transcatheter aortic valve replacement (TF-TAVR). The present study analyses the outcomes after TF-TAVR in patients with or without AF and identifies independent predictors for in-hospital mortality in clinical practice.

Methods and Results Among all 57,050 patients undergoing isolated TF-TAVR between 2008 and 2016 in Germany, 44.2% of patients (n = 25,309) had AF. Patients with AF were at higher risk for unfavorable in-hospital outcome after TAVR. Including all baseline characteristics for a risk-adjusted comparison, AF was an independent risk factor for in-hospital mortality after TAVR. Among patients with AF, EuroSCORE, New York Heart Association classification class, or renal disease had only moderate effects on mortality, while the occurrence of postprocedural stroke or moderate to major bleeding substantially increased in-hospital mortality (odds ratio [OR] 3.35, 95% confidence interval [CI] 2.61–4.30, p < 0.001 and OR 3.12, 95% CI 2.68–3.62, p < 0.001). However, the strongest independent predictor for in-hospital mortality among patients with AF was severe bleeding (OR 18.00, 95% CI 15.22–21.30, p < 0.001).

Conclusion The present study demonstrates that the incidence of bleeding defines the in-hospital outcome of patients with AF after TF-TAVR. Thus, the periprocedural phase demands particular care in bleeding prevention.

Keywords

transcatheter aortic valve replacement - atrial fibrillation - aortic stenosis - bleeding - thromboembolism

* C.M. and P.S. share the last authorship.




Publication History

Received: 27 February 2020

Accepted: 21 July 2020

Article published online:
22 August 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Stuttgart · New York

 

  • References

  • 1 Reinöhl J, Kaier K, Reinecke H. et al. Effect of availability of transcatheter aortic-valve replacement on clinical practice. N Engl J Med 2015; 373 (25) 2438-2447
    CrossrefPubMedGoogle Scholar
  • 2 Durko AP, Osnabrugge RL, Van Mieghem NM. et al. Annual number of candidates for transcatheter aortic valve implantation per country: current estimates and future projections. Eur Heart J 2018; 39 (28) 2635-2642
    CrossrefPubMedGoogle Scholar
  • 3 Mack MJ, Leon MB, Thourani VH. PARTNER 3 Investigators. et al; Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med 2019; 380 (18) 1695-1705
    CrossrefPubMedGoogle Scholar
  • 4 Stachon P, Kaier K, Zirlik A. et al. Risk-adjusted comparison of in-hospital outcomes of transcatheter and surgical aortic valve replacement. J Am Heart Assoc 2019; 8 (07) e011504
    CrossrefPubMedGoogle Scholar
  • 5 Leon MB, Smith CR, Mack MJ. PARTNER 2 Investigators. et al; Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients. N Engl J Med 2016; 374 (17) 1609-1620
    CrossrefPubMedGoogle Scholar
  • 6 Généreux P, Cohen DJ, Mack M. et al. Incidence, predictors, and prognostic impact of late bleeding complications after transcatheter aortic valve replacement. J Am Coll Cardiol 2014; 64 (24) 2605-2615
    CrossrefPubMedGoogle Scholar
  • 7 Seeger J, Gonska B, Rodewald C, Rottbauer W, Wöhrle J. Apixaban in patients with atrial fibrillation after transfemoral aortic valve replacement. JACC Cardiovasc Interv 2017; 10 (01) 66-74
    CrossrefPubMedGoogle Scholar
  • 8 Gilard M, Eltchaninoff H, Donzeau-Gouge P. FRANCE 2 Investigators. et al; Late outcomes of transcatheter aortic valve replacement in high-risk patients: the FRANCE-2 registry. J Am Coll Cardiol 2016; 68 (15) 1637-1647
    CrossrefPubMedGoogle Scholar
  • 9 Tarantini G, Mojoli M, Windecker S. et al. Prevalence and impact of atrial fibrillation in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement: an analysis from the SOURCE XT prospective multicenter registry. JACC Cardiovasc Interv 2016; 9 (09) 937-946
    CrossrefPubMedGoogle Scholar
  • 10 Vora AN, Dai D, Matsuoka R. et al. Incidence, management, and associated clinical outcomes of new-onset atrial fibrillation following transcatheter aortic valve replacement: an analysis from the STS/ACC TVT registry. JACC Cardiovasc Interv 2018; 11 (17) 1746-1756
    CrossrefPubMedGoogle Scholar
  • 11 Mentias A, Saad M, Girotra S. et al. Impact of pre-existing and new-onset atrial fibrillation on outcomes after transcatheter aortic valve replacement. JACC Cardiovasc Interv 2019; 12 (21) 2119-2129
    CrossrefPubMedGoogle Scholar
  • 12 Baumgartner H, Falk V, Bax JJ. ESC Scientific Document Group. et al; 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2017; 38 (36) 2739-2791
    CrossrefPubMedGoogle Scholar
  • 13 January CT, Wann LS, Calkins H. et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2019; 74 (01) 104-132
    CrossrefPubMedGoogle Scholar
  • 14 Nishimura RA, Otto CM, Bonow RO. et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017; 70 (02) 252-289
    CrossrefPubMedGoogle Scholar
  • 15 Dangas GD, Lefèvre T, Kupatt C. BRAVO-3 Investigators. et al; Bivalirudin versus heparin anticoagulation in transcatheter aortic valve replacement: the randomized BRAVO-3 trial. J Am Coll Cardiol 2015; 66 (25) 2860-2868
    CrossrefPubMedGoogle Scholar
  • 16 Kaier K, Oettinger V, Reinecke H. et al. Volume-outcome relationship in transcatheter aortic valve implantations in Germany 2008-2014: a secondary data analysis of electronic health records. BMJ Open 2018; 8 (07) e020204
    CrossrefPubMedGoogle Scholar
  • 17 Kaier K, Reinecke H, Schmoor C. et al. Learning curves among all patients undergoing transcatheter aortic valve implantation in Germany: a retrospective observational study. Int J Cardiol 2017; 235: 17-21
    CrossrefPubMedGoogle Scholar
  • 18 Arnold SV, Zhang Y, Baron SJ. et al. Impact of short-term complications on mortality and quality of life after transcatheter aortic valve replacement. JACC Cardiovasc Interv 2019; 12 (04) 362-369
    CrossrefPubMedGoogle Scholar
  • 19 Mojoli M, Gersh BJ, Barioli A. et al. Impact of atrial fibrillation on outcomes of patients treated by transcatheter aortic valve implantation: a systematic review and meta-analysis. Am Heart J 2017; 192: 64-75
    CrossrefPubMedGoogle Scholar
  • 20 Biviano AB, Nazif T, Dizon J. et al. Atrial fibrillation is associated with increased mortality in patients undergoing transcatheter aortic valve replacement: insights from the Placement of Aortic Transcatheter Valve (PARTNER) trial. Circ Cardiovasc Interv 2016; 9 (01) e002766
    CrossrefPubMedGoogle Scholar
  • 21 Kapadia S, Agarwal S, Miller DC. et al. Insights into timing, risk factors, and outcomes of stroke and transient ischemic attack after transcatheter aortic valve replacement in the PARTNER trial (Placement of Aortic Transcatheter Valves). Circ Cardiovasc Interv 2016; 9 (09) e002981
    CrossrefPubMedGoogle Scholar
  • 22 Huded CP, Tuzcu EM, Krishnaswamy A. et al. Association between transcatheter aortic valve replacement and early postprocedural stroke. JAMA 2019; 321 (23) 2306-2315
    CrossrefPubMedGoogle Scholar
  • 23 Abdul-Jawad Altisent O, Durand E, Muñoz-García AJ. et al. Warfarin and antiplatelet therapy versus warfarin alone for treating patients with atrial fibrillation undergoing transcatheter aortic valve replacement. JACC Cardiovasc Interv 2016; 9 (16) 1706-1717
    CrossrefPubMedGoogle Scholar
  • 24 Guedeney P, Mehran R, Collet JP, Claessen BE, Ten Berg J, Dangas GD. Antithrombotic therapy after transcatheter aortic valve replacement. Circ Cardiovasc Interv 2019; 12 (01) e007411
    CrossrefPubMedGoogle Scholar
  • 25 Mangieri A, Montalto C, Poletti E. et al. Thrombotic versus bleeding risk after transcatheter aortic valve replacement: JACC review topic of the week. J Am Coll Cardiol 2019; 74 (16) 2088-2101
    CrossrefPubMedGoogle Scholar
  • 26 Dangas GD, Tijssen JGP, Wohrle J. GALILEO Investigators. et al; A controlled trial of rivaroxaban after transcatheter aortic-valve replacement. N Engl J Med 2020; 382 (02) 120-129
    CrossrefPubMedGoogle Scholar
  • 27 Nijenhuis VJ, Brouwer J, Delewi R. et al. Anticoagulation with or without clopidogrel after transcatheter aortic-valve implantation. N Engl J Med 2020; 382 (18) 1696-1707
    CrossrefPubMedGoogle Scholar
  • 28 Mangner N, Crusius L, Haussig S. et al. Continued versus interrupted oral anticoagulation during transfemoral transcatheter aortic valve implantation and impact of postoperative anticoagulant management on outcome in patients with atrial fibrillation. Am J Cardiol 2019; 123 (07) 1134-1141
    CrossrefPubMedGoogle Scholar
  • 29 Brinkert M, Keller LS, Moriyama N. et al. Safety and efficacy of transcatheter aortic valve replacement with continuation of oral anticoagulation. J Am Coll Cardiol 2019; 73 (15) 2004-2005
    CrossrefPubMedGoogle Scholar
  • 30 Sun Y, Liu X, Chen Z. et al. Meta-analysis of predictors of early severe bleeding in patients who underwent transcatheter aortic valve implantation. Am J Cardiol 2017; 120 (04) 655-661
    CrossrefPubMedGoogle Scholar
  • 31 Power D, Schäfer U, Guedeney P. et al. Impact of percutaneous closure device type on vascular and bleeding complications after TAVR: a post hoc analysis from the BRAVO-3 randomized trial. Catheter Cardiovasc Interv 2019; 93 (07) 1374-1381
    CrossrefPubMedGoogle Scholar
  • 32 Chamandi C, Abi-Akar R, Rodés-Cabau J. et al. Transcarotid compared with other alternative access routes for transcatheter aortic valve replacement. Circ Cardiovasc Interv 2018; 11 (11) e006388
    CrossrefPubMedGoogle Scholar