Commentary: Postoperative Atrial Fibrillation after Cardiac Surgery: Canary in a Coal Mine?

Abstract Funding Acknowledgements Type of funding sources: None. Background. Postoperative atrial fibrillation (POAF) is the most common arrhythmic complication following cardiac surgery. It may occur between the second and fourth postoperative days as acute POAF, or within 30 days as subacute POAF (sPOAF). The incidence varies from 15% to 60%, with the highest rates observed in patients undergoing valvular surgery. POAF is associated with longer hospital stay and higher thromboembolic risk, which consistently increase patients’ morbidity and mortality. Identification of high-risk categories may allow optimization of in-hospital prevention and treatment, possibly improving clinical outcomes. Aim of the study. The aim of this study was to assess the incidence of sPOAF and to identify possible predictors in patients performing Cardiovascular Rehabilitation (CR) after Cardiac Surgery (CS). Methods. A single-centre retrospective study was performed on 383 post-cardiac surgery patients hospitalised in our CR Unit for inpatient rehabilitation. The entire population was on sinus rhythm at the admission in CR and continuous monitoring with 12-lead ECG telemetry was performed during the hospital stay. We calculated the incidence of sPOAF and then evaluated the predictive value of the following variables: anamnestic data, type of cardiac intervention, clinical course in both CS and CR Unit, laboratory parameters including baseline neutrophil-to-lymphocyte ratio (NLR). Results. Median age was 65 years (63% male). sPOAF was documented in 122 cases (31.9%). Patients developing sPOAF were older [median age 69 (63-76) vs. 61 (51-70); p < 0.001)], more frequently underwent complex surgical procedures (50% vs. 36%; p = 0.009) and were known for previous episodes of atrial fibrillation (27.9% vs. 11.2%; p < 0.001). On the first day after surgery (T1), sPOAF group showed higher values of glycemia [median 155 (126.5–186.8) vs. 129 (106.5–164); p < 0.001] and troponin T [median 721.5 (470.1–1084.3) vs. 488 (301.6-776.2); p < 0.001]. The multivariate analysis identified advanced age (OR 1.04, 95% CI 1.01-1.08; p = 0.023), acute POAF in the Cardiac Surgery Unit (OR 3.51, 95% CI 1.62-7.59; p = 0.001), baseline NLR (OR 1.46, 95% CI 1.10-1.93; p = 0.008) and T1-troponin > 552 ng/L (OR 4.16 95% CI 1.50-11.53; p = 0.006) as independent risk predictors of sPOAF during the CR period. Conclusions. sPOAF is common after cardiac surgery occurring in 31.9% of patients during CR. Age, acute POAF, baseline NLR and elevated troponin T on the first postoperative day were shown predictors of increased sPOAF risk. Recognition of new predictors of POAF could be helpful to better stratify patients, improving management strategies and outcomes.

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Increasing Occurrence of Postoperative Atrial Fibrillation in Contemporary Cardiac Surgery

Journal of Cardiothoracic and Vascular Anesthesia ◽

10.1053/j.jvca.2016.02.013 ◽

2016 ◽

Vol 30 (5) ◽

pp. 1302-1307 ◽

Cited By ~ 6

Author(s):

Jahangir Khan ◽

Niina Khan ◽

Eetu Loisa ◽

Jaakko Sutinen ◽

Jari Laurikka

Keyword(s):

Atrial Fibrillation ◽

Cardiac Surgery ◽

Postoperative Atrial Fibrillation

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Epicardial Adipose Tissue and Postoperative Atrial Fibrillation

10.21203/rs.3.rs-588749/v1 ◽

2021 ◽

Author(s):

Petraglia Laura ◽

Conte Maddalena ◽

Comentale Giuseppe ◽

Cabaro Serena ◽

Campana Pasquale ◽

...

Keyword(s):

Atrial Fibrillation ◽

Adipose Tissue ◽

Cardiac Surgery ◽

Epicardial Adipose Tissue ◽

Perioperative Period ◽

Postoperative Atrial Fibrillation ◽

Serum Samples ◽

Monocyte Chemoattractant Protein 1 ◽

Elective Cardiac Surgery ◽

Increased Risk

Abstract Background. Atrial fibrillation (AF) often occurs after cardiac surgery and is associated to increased risk of stroke and mortality. Several evidence support the important role of inflammation in the pathogenesis of postoperative atrial fibrillation (POAF). It is known that an increased volume and a pro-inflammatory phenotype of epicardial adipose tissue (EAT) are both associated with AF onset in non surgical context. In the present study, we aim to evaluate whether also POAF occurrence may be triggered by an exalted production of inflammatory mediators from EAT.Methods. The study population was composed of 105 patients, with no history of paroxysmal or permanent AF, undergoing elective cardiac surgery. After clinical evaluation, all patients performed an echocardiographic study including the measurement of EAT thickness. Serum samples and EAT biopsies were collected before surgery. Levels of 10 inflammatory cytokines were measured in serum and EAT conditioned media. After surgery, cardiac rhythm was monitored for 7 days.Results. Forty-four patients (41.3%) developed POAF. As regard to cardiovascular therapy, only statin use was significantly lower in POAF patients (65.1% vs. 84.7%; p-0.032). Levels of Monocyte Chemoattractant Protein-1 (MCP-1), in both serum and EAT, were significantly higher in POAF patients (130.1 pg/ml vs. 68.7 pg/ml; p = < 0.001; 322.4 pg/ml vs. 153.4 pg/ml; p = 0.028 respectively). EAT levels of IL-6 were significantly increased in POAF patients compared to those in sinus rhythm (126.3 pg/ml vs. 23 pg/ml; p = < 0.005).ConclusionHigher EAT levels of IL6 and MCP1 are significantly associated with the occurrence of POAF. Statin therapy seems to play a role in preventing POAF. These results might pave the way for a targeted use of these drugs in the perioperative period.

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Metformin therapy and postoperative atrial fibrillation in diabetic patients after cardiac surgery

Journal of Intensive Care ◽

10.1186/s40560-017-0254-8 ◽

2017 ◽

Vol 5 (1) ◽

Cited By ~ 4

Author(s):

Suresh Basnet ◽

Andrzej Kozikowski ◽

Haiyan Sun ◽

Melissa Troup ◽

Luis E. Urrutia ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cardiac Surgery ◽

Postoperative Atrial Fibrillation ◽

Diabetic Patients ◽

Metformin Therapy

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Amiodarone Use to Prevent Postoperative Atrial Fibrillation After Cardiac Surgery

Dimensions of Critical Care Nursing ◽

10.1097/dcc.0b013e31823a52bb ◽

2012 ◽

Vol 31 (1) ◽

pp. 7-12

Author(s):

Blair S. McAlister ◽

Stephanie C. Davis ◽

John J. Whitcomb ◽

Sudhirkumar C. Patel

Keyword(s):

Atrial Fibrillation ◽

Cardiac Surgery ◽

Postoperative Atrial Fibrillation

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ECG Monitoring After Cardiac Surgery

AACN Advanced Critical Care ◽

10.4037/15597768-2007-3008 ◽

2007 ◽

Vol 18 (3) ◽

pp. 294-304

Author(s):

Leslie S. Kern ◽

Marion E. McRae ◽

Marjorie Funk

Keyword(s):

Atrial Fibrillation ◽

Cardiac Surgery ◽

Preventive Therapy ◽

Cost Of Care ◽

Adverse Outcomes ◽

Postoperative Atrial Fibrillation ◽

History Of ◽

Bedside Monitor ◽

Atrial Electrogram ◽

Ventricular Activity

Atrial fibrillation is one of the most common complications after cardiac surgery and is associated with adverse outcomes such as increased mortality, neurological problems, longer hospitalizations, and increased cost of care. Major risk factors for the development of postoperative atrial fibrillation include older age and a history of atrial fibrillation. β-Blockers are the most effective preventive therapy, although sotalol and amiodarone can also be used for prophylaxis. In the postoperative period, the nurse plays an important role in the early detection of atrial fibrillation by the recording of an atrial electrogram, which is easily obtained from the bedside monitor. Because an atrial electrogram records larger atrial activity than ventricular activity, it can be invaluable in establishing the diagnosis of postoperative atrial fibrillation. Once atrial fibrillation begins, treatment can be started with either rhythm conversion or rate-controlling medications.

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Association of smoking with postoperative atrial fibrillation in patients with cardiac surgery

Medicine ◽

10.1097/md.0000000000026179 ◽

2021 ◽

Vol 100 (23) ◽

pp. e26179

Author(s):

Qin Wan ◽

Siyuan Li ◽

Jian Hu

Keyword(s):

Atrial Fibrillation ◽

Cardiac Surgery ◽

Postoperative Atrial Fibrillation

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Abstract 2270: Preoperative Metabolic Therapy Improves Cardiac Surgical Outcomes: A Prospective Randomized Clinical Trial

Circulation ◽

10.1161/circ.116.suppl_16.ii_495-b ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Franklin L Rosenfeldt ◽

Jee Y Leong ◽

Salvatore Pepe ◽

Juliana Van der Merwe ◽

Donald S Esmore ◽

...

Keyword(s):

Atrial Fibrillation ◽

Multivariate Analysis ◽

Cardiac Surgery ◽

Hospital Stay ◽

Lipoic Acid ◽

Troponin I ◽

Myocardial Damage ◽

Postoperative Hospital Stay ◽

Postoperative Atrial Fibrillation ◽

Metabolic Therapy

In the current era the typical patient presenting for cardiac surgery is elderly with multiple co-morbidities. These high-risk patients contribute disproportionately to postoperative morbidity and mortality. We have shown that metabolic therapy with antioxidants such as coenzyme Q 10 (Co Q 10 ) and lipoic acid as well as energy substrate precursors such as orotate have protective effects on the stressed myocardium. We postulated that such therapy would reduce myocardial damage and improve post-operative recovery. Aim: To assess the effects of perioperative metabolic therapy on clinical and biochemical outcomes of cardiac surgery. Methods: Patients ( n =117), mean age 65 years, 74% male, undergoing elective coronary artery bypass graft (CABG) or valve surgery were randomised to receive daily for a minimum of 2 weeks before, and 4 weeks after surgery, metabolic therapy consisting of CoQ 10 300mg, magnesium orotate 1.2g, alpha lipoic acid 300mg, fish oil 999 mg and selenium 200 μg or placebo. Results: In the whole group, metabolic therapy vs placebo was associated (multivariate analysis) with lower 24-hour postoperative plasma troponin I (1.44 ± 0.25 vs 2.65 ± 0.61 ug/L, p =0.003) and reduced postoperative hospital stay (6.9± 0.04 vs 8.1 ± 0.04 days, p =0.002). In CABG alone group (n=70), metabolic therapy reduced the incidence of postoperative atrial fibrillation (23% vs 46%, p =0.04, multivariate analysis). Conclusions: Metabolic therapy before cardiac surgery is associated with: Reduced myocardial damage (troponin I release); Shortened postoperative hospital stay; Reduced incidence of postoperative atrial fibrillation in CABG patients. Clinical and economic benefits may be expected from general application of this therapy.

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Abstract 4102: Preoperative Angiotensin Blocking Drug Therapy Does Not Reduce Atrial Fibrillation After Cardiac Surgery

Circulation ◽

10.1161/circ.118.suppl_18.s_829 ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Florian Rader ◽

Eugene H Blackstone

Keyword(s):

Atrial Fibrillation ◽

Cardiac Surgery ◽

Drug Therapy ◽

Propensity Score ◽

Ace Inhibitors ◽

Postoperative Atrial Fibrillation ◽

Consecutive Series ◽

Blocking Drug ◽

Valvular Surgery ◽

Co Morbidity

Introduction: Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery. Angiotensin blocking drug therapy (ABDT) with Angiotensin converting enzyme (ACE) inhibitors and Angiotensin II receptor blockers (ARBs) has been shown to have anti-arrhythmic effects in animal models. However, data from small observational studies of ABDT use in patients undergoing cardiac surgery had discordant results and did not sufficiently adjust for selection bias. Therefore, we performed the largest study to date examining the association between preoperative use of ABDT and postoperative atrial fibrillation. Methods and Results: A consecutive series of 10,552 patients underwent coronary artery bypass graft (CABG) surgery with or without valvular surgery at Cleveland Clinic between 1997 through 2002. Of these 4,795 (45%) patients were on ABDT within 30 days prior to surgery and 3,633 (34%) patients developed POAF prior to discharge. Without adjusting for patient co-morbidities, ABDT had an Odds Ratio (OR) of 1.13 (95% Confidence Interval (CI) 1.05–1.25, p<0.01). A propensity score matched sample was developed, adjusting for 68 potential confounders. In the 6874 matched patients, who had a well balanced co-morbidity profile, ABDT was not associated with POAF (OR 1.03, CI 0.93–1.12, p=0.67). A subsequent propensity score matched analysis of 3227 patients, who underwent isolated valvular surgery in the same timeframe, also demonstrated ineffectiveness of preoperative ABDT (OR 0.91, CI 0.74 –1.09, p=0.33), irrespective of valve location. Stratified analysis by linear propensity score quintiles and propensity-adjusted logistic multivariable regression analysis of all patients in the CABG and the valvular surgery cohort confirmed these findings. Conclusions: In this large observational study preoperative use of ACE inhibitors or ARBs did not reduce postoperative occurrence of atrial fibrillation in patients undergoing cardiac surgery. Although withdrawal from ABDT prior to surgery is common practice and could account for this result, we cannot recommend such therapy for primary prophylaxis without larger randomized controlled trials.

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