Clinical parameters associated with the development of mortality in patients after non-cardial surgical interventions

Aim. To determine the clinical, instrumental and laboratory factors associated with the development of new-earlypostoperative atrial fibrillation (POAF) in patients after non-cardial surgical interventions. Methods. Cohort retrospective study: 226 case histories were selected from the archive, of which 70 patients were diagnosed with POAF for the first time after non-cardial surgical interventions and 156 patients without it. Results.Patients in the POAF group were statistically significantly older than patients without POAF: the average age was 77 (69;84) years versus 61 (44;71) years (p<0.001), respectively. In addition, patients with POAF were more likely to have a history of myocardial infarction: 30% vs. 8.4% in the group without POAF (p<0.001); more often had a history of cardiac arrhythmias: 35.7% vs. 10.3% with POAF (p<0.001). Thromboembolic complications and pneumonia were more common in the POAF group: 35.7% and 51.4% versus 3.9% and 11%, respectively (p<0.001). There were no differences between the groups in the urgency of surgical intervention. There were also no differences in the volume of postoperative infusion of solutions (p>0.05), the frequency of bleeding after surgery (p=0.290) and the duration of hospitalization (p=0.613).When constructing the logistic regression, it was found that statistically significant independent predictors of POAF development were: myocardial infarction (OR 4.7 at 95% CI 2.2-10.1), history of cardiac arrhythmias (OR 5.0 at 95% CI 2.5-10.3), CHF 2-3 FC (OR 9.9 at 95% CI 5.2-19.1), diabetes mellitus (OR 4.0 at 95% CI 2-8), COPD (OR 8.6 at 95% CI 1.7-42.3), intraoperative infusion of more than 3 liters (OR 3.4 at 95% CI 1.6-7.4). Conclusions.Patients who developed POAF after abdominal surgery are significantly older than patients without POAF, have more pronounced concomitant pathology: they often have a history of myocardial infarction and cardiac arrhythmias, more often suffer from severe chronic heart failure, diabetes mellitus and chronic obstructive pulmonary disease. The development of atrial POAF is more often noted with a large infusion of solutions during surgery, as well as with repeated laparotomies. In the early postoperative period, systemic inflammatory reaction syndrome and thromboembolic complications are more common in patients with POAF.

SummaryBackground:Vitamin D deficiency is associated with many diverse cardiovascular disorders, such as hypertension, heart failure, stroke, coronary artery disease and atrial fibrillation. The relationship between Vitamin D and the development of atrial fibrillation after coronary artery bypass surgery (CABG) has not been studied. Therefore, we assessed the relationship between Vitamin D and the development of postoperative atrial fibrillation (POAF) after CABG.Methods:Medical records of consecutive patients who underwent CABG surgery were retrospectively reviewed for the development of atrial fibrillation in the postoperative period. Vitamin D, other biochemical parameters, and clinical and echocardiographic parameters were evaluated in all patients. The independent variables for the development of postoperative atrial fibrillation were defined and their predictive values were measured.Results:The study group consisted of 128 patients, of whom 41 (32%) developed POAF. Age, diabetes mellitus, chronic obstructive pulmonary disease, history of transient ischaemic attack/stroke, heart failure, left atrial diameter, platelet:largecell ratio, and creatinine, urea, uric acid, calcium and potassium levels were identified as important variables for the development of POAF. However, with logistic regression analysis, chronic obstructive pulmonary disease (OR: 28.737, 95% CI: 0.836–16.118, p < 0.001), heart failure (OR: 15.430, 95% CI: 0.989–7.649, p = 0.006), diabetes mellitus (OR: 11.486, 95% CI: 0.734–11.060, p = 0.001) and left atrial diameter (OR: 1.245, 95% CI: 0.086–6.431, p = 0.011) appeared as independent variables predicting the development of POAF.Conclusion:In our study, although there was a significant negative correlation between Vitamin D and left atrial diameter, Vitamin D level was not an independent predictor for POAF.

Background. Atrial fibrillation (AF) is one of the most common complication after cardiac surgeries. Age, valvular heart disease, heart failure, chronic obstructive pulmonary disease and a history of AF are well known risk factors for postoperative AF. On the other hand, hyponatremia is also a frequent disorder in patients undergoing cardiac surgery but its relationship with AF has not been studied. Purpose. We evaluated the impact of hyponatremia on the incidence of postoperative AF in patients undergoing cardiac surgery with cardiopulmonary bypass. Methods. The retrospective study included case history of 222 patients (174 men and 48 women, median age 64.5 [range 58.0; 69.0] years) who underwent cardiac surgery with cardiopulmonary bypass between January 2015 and December 2018. In all patients intraoperative sodium level was analyzed. Hyponatremia was defined as serum sodium level &amp;lt; 135 mmol/l. Primary outcome was the episode of AF in postoperative period. Results. The incidence of postoperative AF was 18.9% (95% confidence interval (CI) 14.1-24.3 P = 0.05). Patients with AF more often had obesity, diabetes mellitus and a history of myocardial infarction and were more likely to perform combined surgery compared to non-AF patients (all Ps &amp;lt; 0.05). The prevalence of hyponatremia was significantly higher among AF group compared with non-AF (95.2% versus 77.8%, P = 0.017). Hyponatremia was the independent risk factors of postoperative AF in Cox regression models adjusted for covariates (odds ratio 5.31; 95% CI 1.42-18.7; P = 0.017). Conclusion. In this analysis serum sodium level was closely associated with the risk of AF. These findings suggest that hyponatremia may cause the development of postoperative AF in patients undergoing cardiac surgery with cardiopulmonary bypass.

Literature review

Taiwan Atrial Fibrillation Score: A New Clinical Tool for Predicting New Onset Atrial Fibrillation in Asian Populations.

Invited commentary

Potential Preoperative Markers for the Risk of Developing Atrial Fibrillation After Cardiac Surgery

Desarrollo de fibrilación auricular postoperatoria en pacientes hospitalizados en la unidad de cuidado crítico cardiovascular del Hospital San Vicente Fundación entre el periodo 2011 y 2020

Predicting Postoperative Atrial Fibrillation: The Search Continues

The impact of atrial fibrillation on outcomes in patients hospitalized with COVID-19

BACKGROUND Electrocardiography can predict development of postoperative atrial fibrillation (POAF). In renal transplant (RT) recipients, atrial fibrillation is associated with an increased risk of mortality, allograft failure, and stroke. Our study investigated whether P-wave dispersion (PWD) and P-wave peak time (PWPT) can predict the development of POAF in renal transplant recipients. MATERIAL AND METHODS We included 166 patients who underwent RT, divided into 2 groups based on the presence (POAF +) or absence (POAF -) of POAF. Preoperative PWD and PWPT were measured for each patient. RESULTS Smoking, hypertension (HT), chronic obstructive pulmonary disease, and coronary artery disease (CAD) were significantly more common in the POAF (+) group compared to the POAF (-) group. PreopPWD, PWPTDII, and PWPTV1 were significantly higher in the POAF (+) group compared to the POAF (-) group. Univariable logistic regression analysis showed that hypertension, chronic obstructive pulmonary disease, coronary artery disease, and electrocardiographic parameters, including preopPWD, PWPTDII, and PWPTV1, were significantly associated with POAF. Penalized regression analysis showed that HT, CAD, and preoperative PWD were independent predictors of POAF. CONCLUSIONS The integration of these non-invasive, cost-efficient, and readily accessible electrocardiographic parameters into preoperative evaluation protocols could substantially augment risk stratification paradigms, thereby facilitating the timely identification and preemptive management of patients predisposed to POAF.

Background: Diabetes mellitus is an independent risk factor for coronary artery disease and it adversely affects the postoperative outcome after CABG surgery. Adequate control of diabetes for a longer period, which can be assessed by HbA1c, before OPCAB may reduce development of postoperative atrial fibrillation and thus improve outcome.&#x0D; Methods: This was an observational study included sixty diabetic patients purposively who underwent isolated off pump coronary artery bypass procedure in NICVD. Total sample contained 60 diabetic patients, which were divided in two equal groups. Grouping was Group I – 30 Diabetic patients with preoperative HbA1c &lt;7% and Group II – 30 Diabetic patients with preoperative HbA1c ≥7% and all of whom underwent isolated OPCAB. Postoperative atrial fibrillation and other complications were recorded and compared in two groups of patients.&#x0D; Results: Most postoperative atrial fibrillation (AF) developed in higher age group 61-70 years (61.5%). Postoperative complications were higher in group II. Postoperative AF was significantly higher in diabetic patients having preoperative HbA1c ≥7% compare to diabetic patients with HbA1c &lt;7% in early postoperative period after OPCAB. Age (61-70 years) (OR=1.872, p=0.018), preoperative HbA1c ≥7% (OR=19.029, p=0.002) and hypertension (OR=1.091, p=0.019) was found significantly associated with increased development of postoperative atrial fibrillation.&#x0D; Conclusion: Our study revealed that higher preoperative HbA1c level was associated with increased incidence of new onset atrial fibrillation after OPCAB. So, it can be used as a reliable indicator for adequate control of diabetes preoperatively among patients selected for isolated elective OPCAB in future.&#x0D; Cardiovasc. j. 2020; 12(2): 113-119

Letter to the editor:The world medical community has categorised atrial fibrillation (AF) as one of the three cardiovascular ‘epidemics of the 21st century’, along with chronic heart failure and diabetes mellitus [1]. In recent years, the prevalence of AF has increasing steadily. However, the exact cause for the increase in the incidence of AFcannot be explained only by the increase in life expectancy, prevalence of cardiac valve disease or prevalence of myocardial infarction [2].Although AF occurs in individuals with various manifestations of coronary heart disease, it is increasingly being diagnosed in patients with arterial hypertension without coronary heart disease [3]. AF causes serious cardiovascular complications; thus, a deep understanding of its pathogenetic aspects and a comprehensive study that considers comorbid pathologies for identifying the predictors of the development and progression of AF are required [4].Hereditary factors can play a significant role in the development of AF and hypertension; consequently, the worldwide practice of scientific research in basic medicine pays significant attention to the molecular genetics methods of analysis.This study aimed to evaluate the genetic determinants in patients with hypertension with AF progression accompanied by various extra-cardiac comorbid pathologies.This prospective cohort study included 167 patients with a paroxysmal and persistent form of AF and stage III hypertonic disease without coronary heart disease. The average age of the patients was 53.3 ± 7.1 years. DNA isolation from blood leucocytes was performed using phenol–chloroform extraction. The rs1378942 polymorphism of the CSK gene, the rs220073 polymorphism and the -174G/C polymorphism (rs1800795) of the IL6 gene were assessed using polymerase chain reaction-restriction fragment length polymorphism. The statistical hypotheses were considered significant at a critical level of p = 0.05, i.e.the difference was considered statistically significant at p &lt; 0.05. The lower limit of evidentiary power was equal to 80%.This study reported associations between the rs1378942 polymorphism of the CSK gene, the rs1800795 polymorphism of the IL6 gene and the rs220073 polymorphism and the progression of AF in combination with the following associated diseases: hypertension, chronic obstructive pulmonary disease, hypothyroidism, type 2 diabetes mellitus and abdominal obesity. The relative risk of the progression of AF in carriers of the allele C was 1.94 times higher than that in carriers of the allele A [95% confidence interval (CI), 1.21–3.09]. Carriage of the AA genotype was conditionally protective against the progression of AF (relative risk, 0.41; 95% CI, 0.21–0.80; p = 0.010).Associations of the rs1378942 and rs1800795 polymorphisms with the risk of recurrence of AF in combination with certain diseases were also found. In addition, associations were identified between rs1378942 and glomerular filtration rate, systolic and diastolic blood pressure, left atrial wall thickness and glucose, high-density lipoprotein (HDL) cholesterol, triglyceride and creatinine levels; between rs220073 and levels of triglycerides, atherogenic index, creatinine, fibrinogen and the number of months before the development of relapse and between rs1800795 and HDL cholesterol, creatinine and galectin-3 levels and diastolic blood pressure.The secondary form of AF as a multi-factorial disease develops under the influence of many factors of both the external environment and hereditary nature. The complexity of the etio-pathogenesis of the disease makes it extremely difficult for researchers to identify the factors that play a leading role in the development of the pathological process. Currently, associative studies of AF with polymorphisms of &gt;260 genes have been conducted, and genome-wide associative studies have been performed as well. The reproducibility of the results depends on several factors: age, sex, comorbidities, ethnicity, penetrance, expressiveness, pleiotropy, various epigenetic influences and many more.Despite the limitations of the sample, our study adds to the data material already available that can serve in the prognostic assessment of the development and progression of AF. Further studies will allow the development of a personalised algorithm for predicting the progression of AF in hypertension combinedwith extra-cardiac diseases. In this regard, further larger studies are necessary that involve other institutions and a larger sample of patients, which will make it possible to predict the progression of AF with the definition of additional molecular criteria for evaluating the effectiveness of pathogenetic therapy and the possibilities of targeted treatment.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.

&lt;p&gt;&lt;strong&gt;Letter to the editor:&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;The world medical community has categorised atrial fibrillation (AF) as one of the three cardiovascular ‘epidemics of the 21st century’, along with chronic heart failure and diabetes mellitus [1]. In recent years, the prevalence of AF has increasing steadily. However, the exact cause for the increase in the incidence of AF&lt;br /&gt;cannot be explained only by the increase in life expectancy, prevalence of cardiac valve disease or prevalence of myocardial infarction [2].&lt;/p&gt;&lt;p&gt;Although AF occurs in individuals with various manifestations of coronary heart disease, it is increasingly being diagnosed in patients with arterial hypertension without coronary heart disease [3]. AF causes serious cardiovascular complications; thus, a deep understanding of its pathogenetic aspects and a comprehensive study that considers comorbid pathologies for identifying the predictors of the development and progression of AF are required [4].&lt;/p&gt;&lt;p&gt;Hereditary factors can play a significant role in the development of AF and hypertension; consequently, the worldwide practice of scientific research in basic medicine pays significant attention to the molecular genetics methods of analysis.&lt;/p&gt;&lt;p&gt;This study aimed to evaluate the genetic determinants in patients with hypertension with AF progression accompanied by various extra-cardiac comorbid pathologies.&lt;/p&gt;&lt;p&gt;This prospective cohort study included 167 patients with a paroxysmal and persistent form of AF and stage III hypertonic disease without coronary heart disease. The average age of the patients was 53.3 ± 7.1 years. DNA isolation from blood leucocytes was performed using phenol–chloroform extraction. The rs1378942 polymorphism of the CSK gene, the rs220073 polymorphism and the -174G/C polymorphism (rs1800795) of the IL6 gene were assessed using polymerase chain reaction-restriction fragment length polymorphism. The statistical hypotheses were considered significant at a critical level of p = 0.05, i.e.&lt;br /&gt;the difference was considered statistically significant at p &amp;lt; 0.05. The lower limit of evidentiary power was equal to 80%.&lt;/p&gt;&lt;p&gt;This study reported associations between the rs1378942 polymorphism of the CSK gene, the rs1800795 polymorphism of the IL6 gene and the rs220073 polymorphism and the progression of AF in combination with the following associated diseases: hypertension, chronic obstructive pulmonary disease, hypothyroidism, type 2 diabetes mellitus and abdominal obesity. The relative risk of the progression of AF in carriers of the allele C was 1.94 times higher than that in carriers of the allele A [95% confidence interval (CI), 1.21–3.09]. Carriage of the AA genotype was conditionally protective against the progression of AF (relative risk, 0.41; 95% CI, 0.21–0.80; p = 0.010).&lt;/p&gt;&lt;p&gt;Associations of the rs1378942 and rs1800795 polymorphisms with the risk of recurrence of AF in combination with certain diseases were also found. In addition, associations were identified between rs1378942 and glomerular filtration rate, systolic and diastolic blood pressure, left atrial wall thickness and glucose, high-density lipoprotein (HDL) cholesterol, triglyceride and creatinine levels; between rs220073 and levels of triglycerides, atherogenic index, creatinine, fibrinogen and the number of months before the development of relapse and between rs1800795 and HDL cholesterol, creatinine and galectin-3 levels and diastolic blood pressure.&lt;/p&gt;&lt;p&gt;The secondary form of AF as a multi-factorial disease develops under the influence of many factors of both the external environment and hereditary nature. The complexity of the etio-pathogenesis of the disease makes it extremely difficult for researchers to identify the factors that play a leading role in the development of the pathological process. Currently, associative studies of AF with polymorphisms of &amp;gt;260 genes have been conducted, and genome-wide associative studies have been performed as well. The reproducibility of the results depends on several factors: age, sex, comorbidities, ethnicity, penetrance, expressiveness, pleiotropy, various epigenetic influences and many more.&lt;/p&gt;&lt;p&gt;Despite the limitations of the sample, our study adds to the data material already available that can serve in the prognostic assessment of the development and progression of AF. Further studies will allow the development of a personalised algorithm for predicting the progression of AF in hypertension combined&lt;br /&gt;with extra-cardiac diseases. In this regard, further larger studies are necessary that involve other institutions and a larger sample of patients, which will make it possible to predict the progression of AF with the definition of additional molecular criteria for evaluating the effectiveness of pathogenetic therapy and the possibilities of targeted treatment.&lt;br /&gt;&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Funding:&lt;/strong&gt; The study did not have sponsorship.&lt;br /&gt;&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conflict of interest:&lt;/strong&gt; Authors declare no conflict of interest.&lt;/p&gt;

Determination of Histopathologic Risk Factors for Postoperative Atrial Fibrillation in Cardiac Surgery