Prognostic implications of preoperative atrial fibrillation in patients undergoing aortic valve replacement: is there an argument for concomitant arrhythmia surgery?

BACKGROUND: The prognostic significance of preoperative atrial fibrillation (AF) at the time of aortic valve replacement is unknown, as is the potential role for concomitant arrhythmia surgery.
METHODS: We performed a cohort comparison of patients with preoperative AF (n = 129) and preoperative sinus rhythm (SR, n = 252) undergoing aortic valve surgery between 1993 and 2002; patients were matched for age, gender, and left ventricular ejection fraction. Follow-up (mean interval, 4.5 years) was 98% complete. Primary endpoints were late cardiac and all-cause mortality, as well as major adverse cardiac or cerebrovascular event.
RESULTS: Patients with preoperative AF presented with more severe congestive heart failure (p = 0.03) and more often had significant tricuspid regurgitation (p = 0.01) preoperatively. They also had worse late survival (risk ratio [RR] for death = 1.5, p = 0.03) with 1-, 5-, and 7-year survival rates substantially reduced at 94%, 87%, and 50%, respectively, for those in AF versus 98%, 90%, and 61% for patients in sinus rhythm preoperatively. Individuals in AF had a greater probability of subsequent rhythm-related intervention (RR = 4.7, p = 0.0002), and more frequently developed congestive heart failure (25% vs 10%, p = 0.005) and stroke (16% vs 5%, p = 0.005). By multivariable analysis, preoperative AF was an independent predictor of late adverse cardiac and cerebrovascular events, but not late death.
CONCLUSIONS: Performance of concomitant arrhythmia surgery in patients undergoing aortic valve surgery may reduce late morbidity; however, its potential impact on late mortality in this high-risk subset of patients remains unclear.