Post Cardiac Surgery Atrial Post Cardiac Surgery Atrial Fibrillation Fibrillation

Prof. Samir Rafla, FACC, FESC. Alexandria Univ.

smrafla@hotmail.comthe 19th Annual Conference of ESCTS 2013

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Post-operative atrial fibrillation (POAF) is a frequent complication occurring in 30% to 50% of patients after cardiac surgery.

Post-operative AF tends to occur within 2 to 4 days after the procedure, with a peak incidence on postoperative day 2. Seventy percent of patients develop this arrhythmia before the end of post-operative day 4 and 94% before the end of post-operative day 6

Risk FactorsRisk Factors

The most consistent predictor for the The most consistent predictor for the development of POAF is advanced development of POAF is advanced ageage. .

Advanced age is associated with degenerative Advanced age is associated with degenerative and inflammatory modifications in atrial and inflammatory modifications in atrial anatomy (dilation, fibrosis), which cause anatomy (dilation, fibrosis), which cause alterations in atrial electrophysiological alterations in atrial electrophysiological properties (shortness of effective refractoryproperties (shortness of effective refractory

period, dispersion of refractoriness and period, dispersion of refractoriness and conduction, abnormal automaticity,conduction, abnormal automaticity,

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Other risk factors for the development of POAF including a previous history of AF, male gender, decreased LV ejection fraction, left atrial enlargement, valvular heart surgery, chronic obstructive pulmonary disease, chronic renal failure, diabetes mellitus, and rheumatic heart disease .

More recently, More recently, obesityobesity has also been has also been shown to be an independent predictor of shown to be an independent predictor of new-onset AF. The metabolic syndrome new-onset AF. The metabolic syndrome was the only metabolic risk factor to be was the only metabolic risk factor to be independently associated with POAFindependently associated with POAF

Other causes: peri-operative Other causes: peri-operative heart failure and discontinuation of either  and discontinuation of either beta blocker or  or ACE inhibitors before or after surgery, before or after surgery,   pericarditis and elevated postoperative and elevated postoperative adrenergic tone.adrenergic tone.

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Mechanisms based on acute factorsInflammationThe similarity between the time course of AF occurrence after cardiac surgery and the activation of the complement system with the release of pro-inflammatory cytokines suggests an inflammatory component in the mechanism triggering POAF.

Class I

""1.1. Unless contraindicated, treatment with  Unless contraindicated, treatment with an oral an oral beta blocker to prevent  to prevent postoperative postoperative AF is recommended for  is recommended for patients undergoing patients undergoing cardiac surgery. . ((Level of Evidence: A))""

""2.2. Administration of AV nodal blocking  Administration of AV nodal blocking agents is recommended to achieve rate agents is recommended to achieve rate control in patients who develop control in patients who develop postoperative postoperative AF. . ((Level of Evidence: B))""

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Class IIa

""1.1. Preoperative administration of  Preoperative administration of amiodarone reduces the incidence of  reduces the incidence of AF in patients undergoing  in patients undergoing cardiac surgery and represents appropriate prophylactic  and represents appropriate prophylactic therapy for patients at high risk for therapy for patients at high risk for postoperative postoperative AF. . ((Level of Evidence: A))““

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""2.2. It is reasonable to restore  It is reasonable to restore sinus rhythm by  by pharmacological pharmacological cardioversion with  with ibutilide or  or cardioversion in patients who develop  in patients who develop postoperative postoperative AF as advised for nonsurgical  as advised for nonsurgical patients. patients. ((Level of Evidence: B))““

""3.3. It is reasonable to administer  It is reasonable to administer antiarrhythmic medications in an attempt to  in an attempt to maintain maintain sinus rhythm in pts with recurrent or  in pts with recurrent or refractory postoperative refractory postoperative AF, as for other pts , as for other pts who develop who develop AF. . ((Level of Evidence: B))""

Class IIa

-"-"4. 4. It is reasonable to administer It is reasonable to administer antithrombotic medication in pts who  in pts who develop postoperative develop postoperative AF, as for , as for nonsurgical pts. nonsurgical pts. 

Class IIb

- "- "1.1. Prophylactic administration of  Prophylactic administration of sotalol may be considered for patients at risk of  may be considered for patients at risk of developing developing AF following  following cardiac surgery. . ((Level of Evidence: B))""

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Drugs Used for Rate Control in POAF

Drugs Used for Rate Control in POAF

Drugs Used for Rhythm Control in POAFDrugs Used for Rhythm Control in POAF

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Post-Post-CABG, there is an increased risk , there is an increased risk of of strokestroke; hence, ; hence, heparinheparin or  or oral oral anticoagulationanticoagulation may be appropriate if post- may be appropriate if post-op op AFAF persists for longer than 48 hours. persists for longer than 48 hours.

Anticoagulation should be considered if Anticoagulation should be considered if persistent POAF lasts >72 hours and at the persistent POAF lasts >72 hours and at the point of hospital discharge.point of hospital discharge.

Canadian Cardiovascular Society: Atrial Fibrillation Guidelines 2010: Canadian Cardiovascular Society: Atrial Fibrillation Guidelines 2010: Prevention and Treatment of Atrial Fibrillation Following Cardiac Prevention and Treatment of Atrial Fibrillation Following Cardiac Surgery . Surgery . Canadian Journal of Cardiology. Volume 27, Issue 1, January–Canadian Journal of Cardiology. Volume 27, Issue 1, January–February February 20112011, Pages 91–97, Pages 91–97

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Colchicine Reduces Postoperative Atrial Colchicine Reduces Postoperative Atrial FibrillationFibrillation

Conclusion—Conclusion—Colchicine seems safe and Colchicine seems safe and efficacious in the reduction of POAF with efficacious in the reduction of POAF with the potentiality of halving the complication the potentiality of halving the complication and reducing the hospital stay.and reducing the hospital stay.

CIRCULATION CIRCULATION November 16, 2011 November 16, 2011

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Randomized Trial of Atorvastatin for Randomized Trial of Atorvastatin for Reduction of Postoperative Atrial Reduction of Postoperative Atrial Fibrillation in Patients Undergoing Cardiac Fibrillation in Patients Undergoing Cardiac SurgerySurgeryCirculation.Circulation.2006; 114: 1455-14612006; 114: 1455-1461

Conclusions—Conclusions— Treatment with atorvastatin 40  Treatment with atorvastatin 40 mg/d, initiated 7 days before surgery, mg/d, initiated 7 days before surgery, significantly reduces the incidence of significantly reduces the incidence of postoperative AF after elective cardiac surgery postoperative AF after elective cardiac surgery with cardiopulmonary bypass and shortens with cardiopulmonary bypass and shortens hospital stay hospital stay

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Efficacy of posterior pericardiotomy in Efficacy of posterior pericardiotomy in preventing atrial fibrillation after coronary preventing atrial fibrillation after coronary

artery bypass surgery.artery bypass surgery.

CONCLUSIONS: CONCLUSIONS: Posterior pericardiotomy Posterior pericardiotomy seems to significantly reduce the incidence of seems to significantly reduce the incidence of postoperative atrial fibrillation and postoperative atrial fibrillation and supraventricular arrhythmias after coronary supraventricular arrhythmias after coronary artery bypass grafting. The marked reduction of artery bypass grafting. The marked reduction of postoperative pericardial effusion after posterior postoperative pericardial effusion after posterior pericardiotomy suggests that pericardial effusion pericardiotomy suggests that pericardial effusion is one of the main triggers involved in the is one of the main triggers involved in the development of atrial fibrillation after cardiac development of atrial fibrillation after cardiac surgery. surgery. J Thorac Cardiovasc Surg. 2010 May;139:1158-61.J Thorac Cardiovasc Surg. 2010 May;139:1158-61.

Post-operative Atrial FibrillationPost-operative Atrial Fibrillation