Left atrial dysfunction in bicuspid aortic valve patients with severe aortic stenosis is associated with post-operative atrial fibrillation following aortic valve replacement

Johan O Wedin; Sergey Rodin; Frank A Flachskampf; Oscar E Simonson; Johan Pallin; Jonathan Hörsne Malmborg; Stefan K James; Elisabeth Ståhle; Karl-Henrik Grinnemo

doi:10.1093/ehjopen/oeae020

Left atrial dysfunction in bicuspid aortic valve patients with severe aortic stenosis is associated with post-operative atrial fibrillation following aortic valve replacement

Eur Heart J Open. 2024 Mar 28;4(2):oeae020. doi: 10.1093/ehjopen/oeae020. eCollection 2024 Mar.

Authors

Johan O Wedin^{1

2}, Sergey Rodin^{1

2}, Frank A Flachskampf^{3

4}, Oscar E Simonson^{1

2}, Johan Pallin², Jonathan Hörsne Malmborg², Stefan K James^{3

5

6}, Elisabeth Ståhle^{1

2}, Karl-Henrik Grinnemo^{1

2}

Affiliations

¹ Department of Surgical Sciences, Uppsala University Hospital, entrance 70, 1st floor, SE-751 85 Uppsala, Sweden.
² Department of Cardiothoracic Surgery, Uppsala University Hospital, entrance 50, 4th floor, SE-751 85 Uppsala, Sweden.
³ Department of Medical Sciences, Uppsala University Hospital, entrance 40, 5th floor, SE-751 85 Uppsala, Sweden.
⁴ Department of Clinical Physiology, Uppsala University Hospital, entrance 40, 5th floor, SE-751 85 Uppsala, Sweden.
⁵ Department of Cardiology, Uppsala University Hospital, entrance 40, 5th floor, SE-751 85 Uppsala, Sweden.
⁶ Uppsala Clinical Research Center, Uppsala Science Park, Hubben, Dag Hammarskjölds väg 38, SE-751 85 Uppsala, Sweden.

Abstract

Aims: To investigate (i) the association between pre-operative left atrial (LA) reservoir strain and post-operative atrial fibrillation (AF) and (ii) the incidence of post-operative ischaemic stroke events separately in bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients after surgical aortic valve replacement for isolated severe aortic stenosis (AS).

Methods and results: We prospectively enrolled 227 patients (n = 133 BAV and n = 94 TAV) with isolated severe AS scheduled for aortic valve replacement. A comprehensive intra- and inter-observer validated pre-operative echocardiogram with an analysis of LA reservoir strain was performed. Post-operative AF was defined as a sustained (>30 s) episode of AF or atrial flutter. The timing of neurological events was defined in accordance with the Valve Academic Research Consortium-3 criteria for stroke. Post-operative AF occurred in 114 of 227 patients (50.2%), with no difference between BAV and TAV patients (48.1 vs. 53.1%, P = 0.452). Persisting post-operative AF at discharge was more frequent in BAV patients (29.7 vs. 8.0%, P = 0.005). Pre-operative LA reservoir strain was independently associated with post-operative AF (odds ratio = 1.064, 95% confidence interval 1.032-1.095, P < 0.001), with a significant interaction between LA reservoir strain and aortic valve morphology (P_interaction = 0.002). The cumulative transient ischemic attack (TIA)/stroke incidence during follow-up was significantly higher in BAV patients (19.1 vs. 5.8% at 5 years).

Conclusion: Pre-operative LA function was associated with post-operative AF after aortic valve replacement in BAV AS patients, while post-operative AF in TAV AS patients likely depends on transient post-operative alterations and traditional cardiovascular risk factors. TIA/stroke during follow-up was more common in BAV AS patients.

Keywords: Aortic stenosis; Bicuspid aortic valve; Left atrial reservoir strain.