Patients with Atrial Fibrillation Benefit from SAVR with Surgical Ablation Compared to TAVR Alone

Abstract

Introduction: In patients with preoperative atrial fibrillation (AF) undergoing aortic valve replacement, the addition of surgical ablation to surgical aortic valve replacement (SAVR-SA) is efficacious and a Class I guideline. We hypothesized that this subgroup may benefit from SAVR-SA compared to transcatheter aortic valve replacement (TAVR) alone. Methods: Medicare beneficiaries with persistent non-valvular AF who underwent SAVR-SA or TAVR alone between 2012 and 2018 were included. Patients with high-risk surgical comorbidities were excluded. Groups were matched using inverse probability weighting. The primary outcome was all-cause mortality. Secondary outcomes were stroke, transient ischemic attack, permanent pacemaker implantation, bleeding, rehospitalization for atrial arrhythmias, and rehospitalization for heart failure. Kaplan–Meier estimates and Cox proportional-hazards regression were used to compare outcomes. Outcomes were adjusted for variables with a standardized mean difference greater than 0.1. Results: Of 439,492 patients who underwent aortic valve replacement, 2591 underwent SAVR-SA and 1494 underwent TAVR alone. Weighting resulted in adequately matched groups. Compared to TAVR alone, SAVR-SA was associated with a significant reduction in all-cause mortality (HR 0.65, 95% CI 0.53–0.79), permanent pacemaker implantation (HR 0.62, 95% CI 0.44–0.87), bleeding (HR 0.63, 95% CI 0.39–1.00), and rehospitalization for heart failure (HR 0.49 (0.36–0.65). There was no difference in the incidence of stroke (HR 1.07, 95% CI 0.74–1.54), transient ischemic attack (HR 1.05, 95% CI 0.75–1.47), or rehospitalization for atrial arrhythmia. Conclusion: Select patients with persistent non-valvular AF may benefit from SAVR-SA compared to TAVR alone.