Postoperative atrial fibrillation
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]; Varun Kumar, M.B.B.S.
Overview
Post-operative atrial fibrillation is common in cardiac or non-cardiac surgeries. The incidence of atrial fibrillation in post-coronary artery bypass surgery (CABG) and non-cardiac surgery patients are 20%-50% and 0.4%-12%, respectively. pain and inflammation due to surgery, hypovolemia and hypervolemia, anemia, hypoxemia, hypomagnesemia and hypokalemia are some of the known factors in pathogenesis of atrial fibrillation after surgery. Although atrial fibrillation can develop within any time after surgery, it's incidence is higher between second and fifth postoperative day. Advanced age, male gender, obesity, history of chronic obstructive pulmonary disease, valvular heart disease and chronic renal failure are some of the risk factors of post operative atrial fibrillation. To address post operative atrial fibrillation there are both pharmacological and non-pharmacological treatments. In hemodynamically unstable patients, AV nodal blocking agents such as short-acting beta-blockers, nondihydropyridine CCBs or intravenous amiodarone have been shown to improve hemodynamics in patients with post-operative atrial fibrillation. Based on a study, using intravenous analgesics in patients who has pulmonary resection surgery showed significantly lower rates of postoperative atrial fibrillation, compared to the control group.
Postoperative Atrial fibrillation
- Post-operative atrial fibrillation is common in cardiac or non-cardiac surgeries.[1]
- The incidence of atrial fibrillation in post-coronary artery bypass surgery (CABG) patients is between 20% and 50%.[2][3][4]
- The incidence of atrial fibrillation after non-cardiac surgeries is between 0.4% and 12%.[1]
- The following algorithm is a summary of post-operative atrial fibrillation pathophysiology:[1][5][6][7]
| pain due to surgery | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Hypovolemia, Anemia, Hypoxemia | Hypothermia, Hypoglycemia | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Sympathetic outflow elevation | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Myoardial damage | Post-operative atrial fibrillation | Hypokalemia | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Hypervolemia | Inflammation due to surgery | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Hypomagnesemia | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
- Atrial fibrillation can develop within any time after surgery. Nevertheless it's incidence is higher between second and fifth postoperative day.[8]
- The following are some of the general risk factors of post-operative atrial fibrillation:[9][10][11][12]
- Advanced age
- Male patients
- Obesity
- Pericarditis
- History of chronic obstructive pulmonary disease (COPD)
- Valvular heart disease
- Left atrial enlargement
- Peri-operative heart failure
- Discontinuation of either beta blocker or ACE inhibitors before or after surgery
- Elevated postoperative adrenergic tone
- Chronic renal failure
- The following are some of the known risk factors of atrial fibrillation development after non-cardiac surgeries:[13]
- Asthma
- History of valvular heart disease
- Specific procedures, such as abdominal surgeries and extensive vascular surgery
- Intraoperative hypotension
- Paroxysmal form of atrial fibrillation is common post-operatively and is usually self-limiting with sinus rhythm resuming by 6-8 weeks post-surgery in more than 90% of patients.[14]
- Although in many cases post-operative atrial fibrillation is self limiting, the following conditions are considered as well known complications of post-operative atrial fibrillation:[15][16][1]
- Shock
- Stroke
- Perioperative myocardial infarction
- Heart failure
- Ventricular arrhythmias
- Longer period of hospitalization
- Death
- Pre-treatment with either digoxin or verapamil has not shown to prevent postoperative atrial fibrillation.[4][17][18]
- In hemodynamically unstable patients, AV nodal blocking agents such as short-acting beta-blockers, nondihydropyridine CCBs or intravenous amiodarone have been shown to improve hemodynamics in patients with post-operative atrial fibrillation.[19]
- Based on a study, using intravenous analgesics in patients who has pulmonary resection surgery showed significantly lower rates of postoperative atrial fibrillation, compared to the control group.[7]
- Post-coronary artery bypass surgery (CABG), there is an increased risk of stroke; hence, heparin or oral anticoagulation may be appropriate if post-operative atrial fibrillation persists for longer than 48 hours.[20][21]
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)[22]
Postoperative Cardiac and Thoracic Surgery
| Class I |
| "1. Treating patients who develop atrial fibrillation after cardiac surgery with a beta blocker is recommended unless contraindicated. (Level of Evidence: A)" |
| "2. A nondihydropyridine calcium antagonist is recommended when a beta blocker is inadequate to achieve rate control in patients with postoperative atrial fibrillation.(Level of Evidence: B)" |
| Class IIa |
| "1. Preoperative administration of amiodarone reduces the incidence of atrial fibrillation in patients undergoing cardiac surgery and is reasonable as prophylactic therapy for patients at high risk for postoperative atrial fibrillation. (Level of Evidence: A)" |
| "2. It is reasonable to restore sinus rhythm pharmacologically with ibutilide or direct-current cardioversion in patients who develop postoperative atrial fibrillation, as advised for nonsurgical patients. (Level of Evidence: B)" |
| "3. It is reasonable to administer antiarrhythmic medications in an attempt to maintain sinus rhythm in patients with recurrent or refractory postoperative atrial fibrillation, as advised for other patients who develop atrial fibrillation. (Level of Evidence: B)" |
| "4. It is reasonable to administer antithrombotic medication in patients who develop postoperative atrial fibrillation, as advised for nonsurgical patients. (Level of Evidence: B)" |
| "5. It is reasonable to manage well-tolerated, new-onset postoperative atrial fibrillation with rate control and anticoagulation with cardioversion if atrial fibrillation does not revert spontaneously to sinus rhythm during follow-up. (Level of Evidence: C)" |
| Class IIb |
| "1. Prophylactic administration of sotalol may be considered for patients at risk of developing atrial fibrillation following cardiac surgery. (Level of Evidence: B)" |
| "2. Administration of colchicine may be considered for patients postoperatively to reduce atrial fibrillation following cardiac surgery. (Level of Evidence: B)" |
2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)[23][24]
Postoperative AF (DO NOT EDIT)[23][24]
| Class I |
| "1. Unless contraindicated, treatment with an oral beta blocker to prevent postoperative atrial fibrillation is recommended for patients undergoing cardiac surgery. (Level of Evidence: A)" |
| "2. Administration of AV nodal blocking agents is recommended to achieve rate control in patients who develop postoperative atrial fibrillation. (Level of Evidence: B)" |
| Class IIa |
| "1. Preoperative administration of amiodarone reduces the incidence of atrial fibrillation in patients undergoing cardiac surgery and represents appropriate prophylactic therapy for patients at high risk for postoperative atrial fibrillation. (Level of Evidence: A)" |
| "2. It is reasonable to restore sinus rhythm by pharmacological cardioversion with ibutilide or direct current cardioversion in patients who develop postoperative atrial fibrillation as advised for nonsurgical patients. (Level of Evidence: B)" |
| "3. It is reasonable to administer antiarrhythmic medications in an attempt to maintain sinus rhythm in patients with recurrent or refractory postoperative atrial fibrillation, as recommended for other patients who develop atrial fibrillation. (Level of Evidence: B)" |
| "4. It is reasonable to administer antithrombotic medication in patients who develop postoperative atrial fibrillation, as recommended for nonsurgical patients. (Level of Evidence: B)" |
| Class IIb |
| "1. Prophylactic administration of sotalol may be considered for patients at risk of developing atrial fibrillation following cardiac surgery. (Level of Evidence: B)" |
References
- ↑ 1.0 1.1 1.2 1.3 Chelazzi C, Villa G, De Gaudio AR (2011). "Postoperative atrial fibrillation". ISRN Cardiol. 2011: 203179. doi:10.5402/2011/203179. PMC 3262508. PMID 22347631.
- ↑ Soria R, Guize L, Chretien JM, Le Heuzey JY, Lavergne T, Desnos M et al. (1989) [The natural history of 270 cases of Wolff-Parkinson-White syndrome in a survey of the general population.] Arch Mal Coeur Vaiss 82 (3):331-6. PMID: 2502088
- ↑ Creswell LL, Schuessler RB, Rosenbloom M, Cox JL (1993) Hazards of postoperative atrial arrhythmias. Ann Thorac Surg 56 (3):539-49. PMID: 8379728
- ↑ 4.0 4.1 Andrews TC, Reimold SC, Berlin JA, Antman EM (1991) Prevention of supraventricular arrhythmias after coronary artery bypass surgery. A meta-analysis of randomized control trials. Circulation 84 (5 Suppl):III236-44. PMID: 1682069
- ↑ Vretzakis G, Simeoforidou M, Stamoulis K, Bareka M (2013). "Supraventricular arrhythmias after thoracotomy: is there a role for autonomic imbalance?". Anesthesiol Res Pract. 2013: 413985. doi:10.1155/2013/413985. PMC 3819881. PMID 24235971.
- ↑ Liu L, Nattel S (1997). "Differing sympathetic and vagal effects on atrial fibrillation in dogs: role of refractoriness heterogeneity". Am J Physiol. 273 (2 Pt 2): H805–16. doi:10.1152/ajpheart.1997.273.2.H805. PMID 9277498.
- ↑ 7.0 7.1 Jiang Z, Dai JQ, Shi C, Zeng WS, Jiang RC, Tu WF (2009). "Influence of patient-controlled i.v. analgesia with opioids on supraventricular arrhythmias after pulmonary resection". Br J Anaesth. 103 (3): 364–8. doi:10.1093/bja/aep172. PMID 19549643.
- ↑ Davis EM, Packard KA, Hilleman DE (2010). "Pharmacologic prophylaxis of postoperative atrial fibrillation in patients undergoing cardiac surgery: beyond beta-blockers". Pharmacotherapy. 30 (7): 749, 274e–318e. doi:10.1592/phco.30.7.749. PMID 20575638.
- ↑ Mathew JP, Fontes ML, Tudor IC, Ramsay J, Duke P, Mazer CD et al. (2004) A multicenter risk index for atrial fibrillation after cardiac surgery. JAMA 291 (14):1720-9. DOI:10.1001/jama.291.14.1720 PMID: 15082699
- ↑ Dixon FE, Genton E, Vacek JL, Moore CB, Landry J (1986) Factors predisposing to supraventricular tachyarrhythmias after coronary artery bypass grafting. Am J Cardiol 58 (6):476-8. PMID: 3489405
- ↑ Mathew JP, Parks R, Savino JS, Friedman AS, Koch C, Mangano DT; et al. (1996). "Atrial fibrillation following coronary artery bypass graft surgery: predictors, outcomes, and resource utilization. MultiCenter Study of Perioperative Ischemia Research Group". JAMA. 276 (4): 300–6. PMID 8656542.
- ↑ Piechowiak M, Banach M, Ruta J, Barylski M, Rysz J, Bartczak K; et al. (2006). "Risk factors for atrial fibrillation in adult patients in long-term observation following surgical closure of atrial septal defect type II". Thorac Cardiovasc Surg. 54 (4): 259–63. doi:10.1055/s-2006-923955. PMID 16755448.
- ↑ Morsi A, Lau C, Nishimura S, Goldman BS (1998). "The development of sinoatrial dysfunction in pacemaker patients with isolated atrioventricular block". Pacing Clin Electrophysiol. 21 (7): 1430–4. doi:10.1111/j.1540-8159.1998.tb00214.x. PMID 9670187.
- ↑ Kowey PR, Stebbins D, Igidbashian L, Goldman SM, Sutter FP, Rials SJ et al. (2001) Clinical outcome of patients who develop PAF after CABG surgery. Pacing Clin Electrophysiol 24 (2):191-3. PMID: 11270698
- ↑ Echahidi N, Pibarot P, O'Hara G, Mathieu P (2008). "Mechanisms, prevention, and treatment of atrial fibrillation after cardiac surgery". J Am Coll Cardiol. 51 (8): 793–801. doi:10.1016/j.jacc.2007.10.043. PMID 18294562.
- ↑ Kaireviciute D, Aidietis A, Lip GY (2009). "Atrial fibrillation following cardiac surgery: clinical features and preventative strategies". Eur Heart J. 30 (4): 410–25. doi:10.1093/eurheartj/ehn609. PMID 19174427.
- ↑ Kowey PR, Taylor JE, Rials SJ, Marinchak RA (1992) Meta-analysis of the effectiveness of prophylactic drug therapy in preventing supraventricular arrhythmia early after coronary artery bypass grafting. Am J Cardiol 69 (9):963-5. PMID: 1347966
- ↑ Podrid PJ (1999) Prevention of postoperative atrial fibrillation: what is the best approach? J Am Coll Cardiol 34 (2):340-2. PMID: 10440142
- ↑ Clemo HF, Wood MA, Gilligan DM, Ellenbogen KA (1998) Intravenous amiodarone for acute heart rate control in the critically ill patient with atrial tachyarrhythmias. Am J Cardiol 81 (5):594-8. PMID: 9514456
- ↑ Reed GL, Singer DE, Picard EH, DeSanctis RW (1988) Stroke following coronary-artery bypass surgery. A case-control estimate of the risk from carotid bruits. N Engl J Med 319 (19):1246-50. DOI:10.1056/NEJM198811103191903 PMID: 3263571
- ↑ Taylor GJ, Malik SA, Colliver JA, Dove JT, Moses HW, Mikell FL et al. (1987) Usefulness of atrial fibrillation as a predictor of stroke after isolated coronary artery bypass grafting. Am J Cardiol 60 (10):905-7. PMID: 3661408
- ↑ January, C. T.; Wann, L. S.; Alpert, J. S.; Calkins, H.; Cleveland, J. C.; Cigarroa, J. E.; Conti, J. B.; Ellinor, P. T.; Ezekowitz, M. D.; Field, M. E.; Murray, K. T.; Sacco, R. L.; Stevenson, W. G.; Tchou, P. J.; Tracy, C. M.; Yancy, C. W. (2014). "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society". Circulation. doi:10.1161/CIR.0000000000000041. ISSN 0009-7322.
- ↑ 23.0 23.1 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA; et al. (2011). "2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". J Am Coll Cardiol. 57 (11): e101–98. doi:10.1016/j.jacc.2010.09.013. PMID 21392637.
- ↑ 24.0 24.1 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 114 (7):e257-354. DOI:10.1161/CIRCULATIONAHA.106.177292 PMID: 16908781