12 Aug New Onset Atrial Fibrillation Strongest Predictor of Stroke After TAVR
MedicalResearch.com Interview with:
Josep Rodés-Cabau, MD
Director, Catheterization and Interventional Laboratories
Quebec Heart and Lung Institute
Professor, Faculty of Medicine, Laval University
Quebec City, Quebec, Canada
MedicalResearch.com: What is the background for this study?
Response: Transcatheter aortic valve replacement (TAVR) is increasingly used in patients with severe aortic stenosis deemed at prohibitive or high surgical risk. Recently, a randomized trial demonstrated the non-inferiority of TAVR compared to surgical aortic valve replacement in intermediate risk patients for the outcome of death and disabling stroke at 2 years. Therefore, TAVR indications are likely to expand to younger and lower risk patients in the near future.
While the short-term (30-day) cerebrovascular event (CVE) rate post-TAVR has decreased over time, it remains the most dreadful complication of TAVR, and still occurs in 2% to 3% of patients. A few dedicated studies identified numerous predictors of CVE which mainly differ from one study to another. However, identifying the risk factors of CVE is of paramount relevance in clinical practice to implement preventive strategies, either instrumental (embolic protection devices) or pharmacological in high-risk patients. Thus, we performed a systematic review and meta-analysis using random-effect models to provide pooled estimates of sixteen (8 patient-related and 8 procedural-related) clinically-relevant predictors of CVE within 30 days post TAVR.
MedicalResearch.com: What are the main findings?
Response: Amongst patient-related risk factors, only female sex (RR: 1.21; 95% CI: 1.03-1.43) and chronic kidney disease defined by an estimated glomerular filtration rate < 60 ml/(min•1.73 m²) (RR: 1.29; 95% CI: 1.03-1.63 ) associated with CVE. Amongst procedural-related predictors, procedures performed within the first half of centers’ experience (RR: 1.55; 95% CI: 1.16-2.08) and new-onset atrial fibrillation (RR: 1.85; 95% CI: 1.20-2.84) both associated with a higher risk of CVE.
Interestingly, valve type and approach exhibited no association with short term CVE confirming the findings of prior studies.
MedicalResearch.com: What should readers take away from your report?
Response: Our analysis provides effect estimates for numerous clinically-relevant variables and as such represent a first step to guide the implementation of further preventive measures. Among other, considering that new-onset atrial fibrillation was the strongest predictor of short-term CVE, our results support the need for continuous rhythm monitoring during hospitalization post-TAVR and suggest the prompt consideration of anticoagulation in patients presenting with this complication.
Readers should also be aware of the limitations of the present work. Given the important heterogeneity in reporting stroke in the current literature, we had to pool different outcomes. Moreover, despite this methodology, amongst selected predictors, the actual numbers of events/patients remained somewhat limited and thus the possibility of a type II error by lack of statistical power should be kept in mind. Finally, we used crude risk-ratio as our outcomes measure and confounding cannot be ruled out making it impossible to identify the true independent influence of each predictor.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Response: First of all, our experience reinforces the need for uniform and exhaustive reporting of events in the field of TAVR using the Valve Academic Research Consortium definitions. This will improve the comparability across studies and facilitate the performance of future systematic reviews and meta-analysis.
Future efforts should aim at defining more precisely which TAVR recipients are most likely to benefit from tailored therapies: e.g. use of embolic protection devices in high-risk subsets of patients, optimizing antithrombotic therapy post-TAVR while taking into account the bleeding risks.
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Auffret V, Regueiro A, Del Trigo M, et al. Predictors of Early Cerebrovascular Events in Patients With Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement. J Am Coll Cardiol. 2016;68(7):673-684. doi:10.1016/j.jacc.2016.05.065.
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