Fibrillation In Cardiac Surgery Patients Research Articles

Abstract 18220: Does Mineralocorticoid Receptor Blockade Affect the Occurrence of Perioperative Atrial Fibrillation in Cardiac Surgery Patients? - A Systematic Review and Meta-Analysis

Background: Mineralocorticoid receptor antagonists (MRAs) have emerged as potential therapy to prevent atrial fibrillation (AF). However, inconsistent results of MRAs effect on perioperative AF have been reported in the literature in patients undergoing cardiac surgery. To our knowledge, this is the first metanalysis to assess the effect of MRAs on occurrence of perioperative AF in patients undergoing cardiac surgery. Method: We searched different electronic databases from inception to April 30th, 2023, for randomized controlled trials (RCTs) and observational studies that evaluated the use of MRAs in patients with heart failure and left ventricular ejection fraction (LVEF) 30-50% who were referred for Coronary Artery Bypass Grafting (CABG) and/or valve surgery without any AF history. Primary outcome was occurrence of perioperative AF. Three independent reviewers selected and appraised the data. A random-effects meta-analysis was performed to estimate pooled odds ratios (OR) and 95% confidence intervals (CI). Result: We included 4 studies, 1 RCT and 3 observational cohorts, with a cumulative number of 1,128 patients with mean age 65.15 years. 412(36.5%) received an MRA (spironolactone or eplerenone). The follow up duration was 5 days to 1 month. During follow-up, 118 (28.64%) patients treated with MRAs, developed AF, compared to 224 (31.28%) patients, without MRA treatment. However, metanalysis showed that there is no significant reduction in occurrence of perioperative AF in MRA treated patients (OR: 0.88 CI: 0.58-1.33 p=0.55), I2 53%; Figure] Conclusion: Experimental data have shown that MRA blockade prevents perioperative AF in animal models but our metanalysis demonstrated that MRAs were not protective for perioperative AF in patients undergoing cardiac surgery. Larger trials in humans are warranted to evaluate its efficacy, particularly in patients undergoing cardiac surgery.

Abstract 11520: Safety and Efficacy of Botulinum Toxin Type A for Prevention of Postoperative Atrial Fibrillation in Cardiac Surgery Patients: Pulmonary Function Test Results From the Phase 2 NOVA Study

Background: Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery. Autonomic neuromodulation, including injection of botulinum toxin into epicardial fat pads, may suppress and/or attenuate atrial fibrillation. The respiratory safety of a potential preventative treatment for AF is critical. Aim: To assess efficacy and pulmonary safety of botulinum toxin type A (BoNT/A; AGN-151607) 125U and 250U vs placebo for prevention of POAF after coronary artery bypass graft and/or valve surgery. Methods: NeurOtoxin for the PreVention of post-operative Atrial fibrillation (NOVA; NCT03779841) was a phase 2, international, multicenter, randomized, placebo-controlled trial. The primary endpoint was proportion of patients with continuous AF ≥30 seconds within the first 30 days. Respiratory function was assessed via pulmonary function tests (PFTs) performed at baseline and day 30 after treatment. Adverse events (AEs), serious adverse events (SAEs), and time to extubation were recorded. Results: A total of 323 patients were randomized: BoNT/A 125U (n=106), 250U (n=109), placebo (n=108). The primary endpoint occurred in 46.1% of the placebo group, 36.5% of the 125U group (relative risk [RR] vs placebo, 0.80 [95% CI: 0.58, 1.10]; P =0.16), and 47.2% of the 250U group (RR vs placebo, 1.04 [95% CI: 0.79, 1.37]; P =0.78). Baseline, day 30, and change from baseline PFT results were similar for active treatment vs placebo ( Table ). Median time to extubation was 9.7, 9.6, and 9.6 h in the placebo, 125U, and 250U groups, respectively. Respiratory AEs were reported in 42.9%, 38.1%, and 50.5% of patients, and respiratory SAEs in 11.4%, 6.7%, and 5.5% of patients in the placebo, 125U, and 250U groups, respectively. Conclusion: In this analysis of respiratory function, there appeared to be no detrimental effect of AGN-151607 compared with placebo, as evidenced by similar outcomes in PFT parameters and respiratory AE/SAE incidences among treatment arms.

Pericardial Inflammatory Mediators That Can Drive Post-Operative Atrial Fibrillation in Cardiac Surgery Patients.

Post-operative atrial fibrillation (POAF) is a common dysrhythmia that affects a significant number of patients undergoing cardiac surgery. Many studies aim to better understand this complex post-surgical complication by analyzing circulating biomarkers in patients who develop POAF. More recently, the pericardial space is shown to contain inflammatory mediators that could trigger POAF. In this review we summarize recent studies that examine the immune mediators present in the pericardial space and their potential implications for the pathophysiology of POAF in cardiac surgery patients. Ongoing research in this area should better delineate the multi-factorial etiology of POAF, where specific markers may be targeted to reduce the incidence of POAF and improve outcomes for this patient population. Key words: Post-operative atrial fibrillation; pericardium; pericardial fluid; epicardial adipose tissue; inflammation; cardiac surgery.

Factors affecting the occurrence of postoperative atrial fibrillation in cardiac surgery patients

Abstract Funding Acknowledgements Type of funding sources: None. Intorduction. Postoperative atrial fibrillation (POAF) is the most common arrhythmia after cardiac surgery and is a serious clinical problem. POAF refers to new-onset atrial fibrillation developing immediately after surgery. Despite advances in surgical and perioperative techniques, it remains the most common adverse event in cardiac surgery. Many studies are being conducted to obtain detailed information on the mechanisms underlying POAF, its course and effective treatment methods. Despite a significant improvement in treatment outcomes after cardiac surgery, the incidence of POAF did not change. It continues to be a major burden for patients, physicians and healthcare systems increasing hospitalization and healthcare costs as reflected in longer hospital stays, increased post-operative complications and increased mortality. Purpose Identification of factors determining the occurrence of POAF in patients after cardiac surgery. Material and Methods 125 patients (53 women, 72 men, mean age 68.68 ± 7.11) qualified for elective cardiac surgery were included in the study. Patients with persistent or paroxysmal atrial fibrillation diagnosed before the procedure were excluded from the study. The study took into account a number of sociodemographic and clinical data, which were collected on the basis of patients' medical records from the course of hospitalization (sex, age, weight, height, BMI, place of residence, type of surgery, duration of surgery, perioperative risk according to EuroScore II, results of laboratory tests before and after surgery, the presence of comorbidities and multi-morbidity, hospitalization time). In addition, the score obtained in the CHA2DS2–VASc scale was taken into account in the analysis. The assumed significance level was p < 0.05. Results POAF was identified in 41% of patients. The average perioperative risk in the study group was M± SD = 2.05 ± 1.61. It was noted that POAF is significantly more common in women than in men (21.6% vs. 19.2%; p = 0.048). Patients with POAF had a significantly higher BMI than patients without POAF (29.20±3.81 vs. 27.89±4.14, p = 0.38). In patients with POAF, a statistically significant correlation was found between the loss of platelets during the procedure and the length of hospitalization (r = -0.387, p<0.005). In the study group, there was no relationship between the occurrence of POAF and the type of surgery, duration of surgery, loss of hemoglobin, total protein, decrease in potassium levels, the presence of comorbidities, multimorbidity, CHA2DS-VAc score). Conclusions 1. Female sex is an unmodifiable factor determining the occurrence of POAF in cardiac surgery. 2. Overweight is a modifiable factor determining the occurrence of POAF in cardiac surgery. 3. Perioperative platelet loss in patients with POAF results in longer hospital stay after cardiac surgery.

Association of CHA2DS2-VASc Score with Post Cardiac Surgery Atrial Fibrillation: A Single Centre Study

Objective: To find out the association of CHA2DS2-VASc score with postoperative atrial fibrillation in cardiac surgery patients.
 Study Design: Analytical Cross-Sectional study.
 Place and Duration of Study: Cardiothoracic Anaesthesia and Adult Cardiac Critical Care department, Armed Forces Institute of Cardiology and National Institute of Heart Diseases (AFIC/NIHD), Rawalpindi Pakistan, from Feb 2022 to Apr 2022.
 Methodology: After IERB approval, 186 adult patients of POAF with the prevalence of 9.7%undergoing CABG surgery were included in the study. Their demographic data and CHA2DS2-VASc score, originally used to find the risk of stroke in patients with atrial fibrillation, was calculated pre-operatively. They were followed for 48 hours postoperatively for any episode of post op atrial fibrillation (POAF). Data including pre op drugs, type of surgery, number of grafts, inotropic support and POAF timing after surgery was recorded and analysed by SPSS v 21.0.
 Results: Incidence of POAF in our study patients was 17.2 %( n=32). Mean time of onset of POAF was 24.75±16.05 hours.Patients who developed POAF had higher CHA2DS2-VASc score 3.06±1.21 compared with those who did not develop POAF 2.61±0.97. This association was statistically significant (p-value=0.023). Among the variables of CHA2DS2-VASc score, age had significant association with POAF (p-value= 0.001). No difference was found between on pump vs off pump surgery in terms of POAF (p-value=0.539).
 Conclusion: This study found that CHA2DS2-VASc score has significant association with POAF after CABG surgery. It is a simple and easy scoring system which can be calculated in preoperative period. Patients at increased risk of POAF can be identified and given prophylactic treatment to reduce morbidity and mortality.

Preoperative mental illness and postoperative atrial fibrillation in cardiac surgery patients: Identifying a vulnerable population.

Preoperative mental illness and postoperative atrial fibrillation in cardiac surgery patients: Identifying a vulnerable population.

Predictive Capability of Metabolic Panels for Postoperative Atrial Fibrillation in Cardiac Surgery Patients

IntroductionPostoperative atrial fibrillation (POAF) occurs in up to 65% of cardiac surgery patients and is associated with an increased risk for stroke and mortality. Electrolyte disturbances in sodium (Na+), potassium (K+), total calcium (Ca2+), chloride (Cl−), and magnesium (Mg2+) are predisposing factors for POAF, but these imbalances are yet to be used to predict POAF. The purpose of this study is to determine whether the development of POAF can be predicted by blood plasma ionic composition. MethodsMetabolic panels of patients with no prior history of atrial fibrillation who did (n = 763) and did not develop POAF (n = 2144) after cardiac surgery were obtained from the Carilion Clinic electronic medical record system. We initially evaluated serum Na+, K+, Ca2+, Cl−, and Mg2+ in the two groups using descriptive statistics via scatter and spaghetti plots and then with predictive modeling via logistic regression and random forest models. ResultsNeither scatter nor spaghetti plots of electrolyte data revealed a significant difference between those who did and did not develop POAF. Two logistic regression models and two random forest models with POAF status as the outcome were generated using the first observation for each electrolyte and the coefficient of the linear regression, which was obtained from a linear fit of the scatter plot. The random forest model using the first observation had a sensitivity of only 12.2%, but all four models had specificities more than 97%. ConclusionsNeither of the two logistic regression nor two random forest models were able to effectively predict the development of POAF from plasma ionic concentrations, but the random forest models effectively classified patients who would not develop POAF.

Metoprolol for prophylaxis of postoperative atrial fibrillation in cardiac surgery patients: systematic review and meta-analysis

PurposePostoperative atrial fibrillation (POAF) is a potentially lethal and morbid complication after open heart surgery. This systematic review and meta-analysis aimed to investigate metoprolol compared with other treatments for prophylaxis...

RNAs and Gene Expression Predicting Postoperative Atrial Fibrillation in Cardiac Surgery Patients Undergoing Coronary Artery Bypass Grafting.

Postoperative atrial fibrillation (POAF) is linked with increased morbidity, mortality rate and financial liability. About 20–50% of patients experience POAF after coronary artery bypass graft (CABG) surgery. Numerous review articles and meta-analyses have investigated links between patient clinical risk factors, demographic conditions, and pre-, peri- and post-operative biomarkers to forecast POAF incidence in CABG patients. This narrative review, for the first time, summarize the role of micro-RNAs, circular-RNAs and other gene expressions that have shown experimental evidence to accurately predict the POAF incidence in cardiac surgery patients after CABG. We envisage that identifying specific genomic markers for predicting POAF might be a significant step for the prevention and effective management of this type of post-operative complication and may provide critical perspective into arrhythmogenic substrate responsible for POAF.

Effect of Sex on Incidence of Post-Operative Atrial Fibrillation in Cardiac Surgery Patients

Post-operative atrial fibrillation (POAF) is common in cardiac surgery patients. Female sex is an independent predictor for poorer outcomes after cardiac surgery. This study sought to investigate if sex is associated with the incidence of POAF.

Management of postoperative atrial fibrillation in cardiac surgery patients.

Postoperative atrial fibrillation (AF) is a common arrhythmia following cardiac surgery and contributes to patient morbidity, prolonged hospital stay, and increased financial costs. The risk of postoperative AF may increase based on patient characteristics or events that occur intraoperatively or postoperatively. An understanding of these risks may be helpful in identifying which patients would benefit from prevention strategies. Acute AF presentation may range from completely indolent to rapidly progressing hemodynamic instability. Patients without hemodynamic compromise can be managed conservatively with rate control or initiation of antiarrhythmic medications. Patients with significant hemodynamic instability should undergo direct current cardioversion. In the postoperative period, it is reasonable to initiate anticoagulation after 48 hours of sustained AF or frequent episodes of postoperative AF.

Predicting New-Onset Postoperative Atrial Fibrillation in Cardiac Surgery Patients.

To derive a simple clinical prediction rule identifying patients at high risk of developing new-onset postoperative atrial fibrillation (POAF) after cardiac surgery. Retrospective analysis on prospectively collected observational data. A university-affiliated cardiac hospital. Adult patients undergoing coronary artery bypass grafting and/or valve surgery. Observation for the occurrence of new-onset postoperative atrial fibrillation. Details on 28 preoperative variables from 999 patients were collected and significant predictors (p<0.2) were inserted into multivariable logistic regression and reconfirmed with recursive partitioning. A total of 305 (30.5%) patients developed new-onset POAF. Eleven variables were associated significantly with atrial fibrillation. A multivariable logistic regression model included left atrial dilatation, mitral valve disease, and age. Coefficients from the model were converted into a simple 7-point predictive score. The risk of POAF per score is: 15.0%, if 0; 20%, if 1; 27%, if 2; 35%, if 3; 44%, if 4; 53%, if 5; 62%, if 6; and 70%, if 7. A score of 4 has a sensitivity of 44% and a specificity of 82% for POAF. A score of 6 has a sensitivity of 11% and a specificity of 97%. Bootstrapping with 5,000 samples confirmed the final model provided consistent predictions. This study proposed a simple predictive score incorporating three risk variables to identify cardiac surgical patients at high risk of developing new-onset POAF. Preventive treatment should target patients ≥ 65 years with left atrial dilatation and mitral valve disease.

Abstract 288: Vitamin C Decreases Atrial Fibrillation In Cardiac Surgery Patients But Vitamin E May Decrease Response: A Randomized-controlled Trial Meta-analysis

Background: Due to the population aging, atrial fibrillation (AF) is becoming a more prevalent disease, it also commonly presents as a cardiac surgery complication. Randomized controlled trials (RCT) concerning anti-oxidant vitamins for atrial fibrillation (AF) prophylaxis have yielded inconsistent outcomes. Similar inconsistencies were found in other cardiovascular studies, as the HOPE and FATS studies, suggesting that vitamin E in special may not be helpful, perhaps harmful. Methods: All randomized controlled trials on anti-oxidant vitamins supplementation for atrial fibrillation prevention for patients undergoing cardiac surgery were sought in Medline and Cochrane databases during May 2012. Data was extracted by 3 reviewers. Results: Seven studies were found, three with vitamin C, two with Vitamin E and two combining both. We found an overall significant 60% decrease in the overall chance for AF occurrence mostly driven by (Figures1A and 1B) as the studies with vitamin E or vitamin C and E combined (Figures 1 C and 1D) did not show a statistically significant difference. When all studies with Vitamin E alone or in combination with Vitamin C (Figure 1E). Conclusions: Vitamin C supplementation decreases the incidence of post cardiac surgery AF but the data on Vitamin E is inconsistent, it may even decrease the Vitamin C benefit. As vitamin self-supplementation is extremely common in the US, large trials are extremely important not only for benefit confirmation but to exclude potential harms.

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Introduction: Antioxidant supplementation has been shown to decrease post-operative atrial fibrillation in cardiac surgery patients. A high-dose antioxidant supplementation protocol of ascorbic acid, selenium, and vitamin E for 7 days was implemented at our institution in October 2005 for patients admitted to the Trauma ICU. Previous studies in trauma patients demonstrated that antioxidant supplementation decreases mortality and hospital/ICU length of stay. The purpose of this study is to determine if the incidence of atrial arrhythmias is reduced in trauma patients receiving high-dose antioxidant supplementation. Hypothesis: We hypothesize that antioxidant supplementation decreases the incidence of atrial arrhythmias in trauma patients. Methods: In this single-center, retrospective cohort study at Vanderbilt University Medical Center, patients?18 years of age and admitted to the Trauma ICU for? 48 hours were eligible for inclusion. The antioxidant group consists of patients admitted from October 2005 to June 2011 who received the antioxidant protocol for? 48 hours. The control group consists of patients admitted from January 2000 to September 2005, prior to antioxidant supplementation. Patients experiencing arrhythmias were identified by ICD-9 codes. The primary outcome is the incidence of atrial arrhythmias in the first two weeks of hospitalization or prior to discharge. Results: There were 4,691 patients in this study (1,622 patients in the antioxidant group and 2,414 patients in the control group). The incidence of atrial arrhythmias was 3.02% in the antioxidant group versus 3.31% in the control group (P = 0.096; Adj OR[95% CI]: 1.64 [0.92, 2.93]). There was no difference in the average time to arrhythmia occurrence. The expected survival time of patients in the control group was decreased compared to those receiving antioxidant therapy (Adj TR[95% CI]: 0.65 [0.43, 0.97]). Conclusions: The high-dose antioxidant protocol did not significantly decrease the incidence of atrial arrhythmias in trauma patients. This study confirmed the benefit of decreased hospital mortality seen in previous studies of antioxidant supplementation at our institution.

Effect of Preoperative Atrial Fibrillation on Postoperative Outcome following Cardiac Surgery

Atrial fibrillation remains the commonest arrhythmia encountered in cardiac surgery. Data on the effect of preoperative atrial fibrillation on postoperative outcome remain limited. We sought to assess the effects preoperative atrial fibrillation on patients' outcome following cardiac surgery. This is a retrospective review of prospectively collected departmental data of all patients who underwent cardiac surgery over 8-year period. Our cohort consisted of 3777 consecutive patients divided into atrial fibrillation (n = 413, 11%) and sinus rhythm (n = 3364, 89%). Postoperative complications and in-hospital mortality were analysed. Univariate analysis showed significantly increased mortality and major complications in atrial fibrillation compared to sinus rhythm patients. Using multiple logistic regression analysis and after accounting for Euro SCORE as a confounding variable, we found that preoperative atrial fibrillation significantly increases the risk of mortality (OR 1.7), low cardiac output state (OR 1.3), prolonged ventilation (OR 1.4), infective complication (OR 1.5), gastrointestinal complications (OR 2.0), and intensive care unit readmission (OR 1.6). Preoperative atrial fibrillation in cardiac surgery patients increases their risk of mortality and major complications following cardiac surgery. Surgical strategies such as Cox-Maze procedure may be beneficial in these patients.

Do Omega-3 fatty acids prevent atrial fibrillation after open heart surgery? A meta-analysis of randomized controlled trials

OBJECTIVES:N-3 polyunsaturated fatty acids have been proposed as a novel treatment for preventing postoperative atrial fibrillation due to their potential anti-inflammatory and anti-arrhythmic effects. However, randomized studies have yielded conflicting results. The objective of this study is to review randomized trials of N-3 polyunsaturated fatty acid use for postoperative atrial fibrillation.METHODS:Using the CENTRAL, PUBMED, EMBASE, and LILACS databases, a literature search was conducted to identify all of the studies in human subjects that reported the effects of N-3 polyunsaturated fatty acids on the prevention of postoperative atrial fibrillation in cardiac surgery patients. The final search was performed on January 30, 2011. There was no language restriction, and the search strategy only involved terms for N-3 polyunsaturated fatty acids (or fish oil), atrial fibrillation, and cardiac surgery. To be included, the studies had to be randomized (open or blinded), and the enrolled patients had to be ≥18 years of age.RESULTS:Four randomized studies (three double-blind, one open-label) that enrolled 538 patients were identified. The patients were predominantly male, the mean age was 62.3 years, and most of the patients exhibited a normal left atrial size and ejection fraction. N-3 polyunsaturated fatty acid use was not associated with a reduction in postoperative atrial fibrillation. Similar results were observed when the open-label study was excluded.CONCLUSIONS:There is insufficient evidence to suggest that treatment with N-3 polyunsaturated fatty acids reduces postoperative atrial fibrillation. Therefore, their routine use in patients undergoing cardiac surgery is not recommended.

Perioperative atrial fibrillation in cardiac surgery patients: Echocardiographic findings

Perioperative atrial fibrillation in cardiac surgery patients: Echocardiographic findings

Prophylaxis Against Atrial Fibrillation After Cardiac Surgery: Effective, But Not Routinely Used—A Survey of Cardiothoracic Units in the United Kingdom

To establish whether international recommendations on chemoprophylaxis against postoperative atrial fibrillation in cardiac surgery patients are implemented locally in cardiothoracic units in the United Kingdom; to determine which drugs are being used, how long they are given, and whether outcomes are monitored. Survey of local cardiothoracic center guidelines. Postal and telephone survey. Senior anesthesiologists and critical care staff in all 37 public cardiothoracic units in the United Kingdom. None. Results were obtained from all contacted cardiothoracic units. Five units (14%) have local guidelines for chemoprophylaxis against atrial fibrillation in place. All use β-antagonists as their primary prophylactic drugs; only one unit uses amiodarone as a secondary prophylactic drug. Duration of prophylactic treatment varies, from 5 days to 6 weeks postoperatively. Thirty-two units (86%) have no local guidelines for chemoprophylaxis in place. Chemoprophylaxis against postoperative atrial fibrillation in cardiac surgery patients remains underused, despite its effectiveness and recommendations for its routine use by several international organizations. Departmental guidelines help to ensure routine use, but this survey shows that so far only a minority of cardiothoracic units in the United Kingdom have implemented such guidelines. Awareness of the advantages of routine prophylaxis against atrial fibrillation should be improved and departmental prescribing policies encouraged.

Preoperative left atrial dysfunction and new-onset atrial fibrillation in cardiac surgery patients

Postoperative atrial fibrillation is one of the most frequent complications after cardiopulmonary bypass (CPB). The aim of the present study was to investigate the correlation between preoperative left atrial dysfunction assessed by tissue Doppler and postoperative new-onset atrial fibrillation (NOAF) after coronary artery bypass grafting (CABG).

Electrocardiographic Activity before Onset of Postoperative Atrial Fibrillation in Cardiac Surgery Patients

Electrocardiographic (ECG) characteristics were analyzed in postoperative cardiac surgery patients in an attempt to predict development of new-onset postoperative atrial fibrillation (AF). Nineteen ECG characteristics were analyzed using computer-based algorithms. The parameters were retrospectively analyzed from ECG signals recorded in postoperative cardiac surgery patients while they were in the cardiovascular intensive care unit (CVICU) at our institution. ECG data from 99 patients (of whom 43 developed postoperative AF) were analyzed. A bootstrap variable selection procedure was applied to select the most important ECG parameters, and a multivariable logistic regression model was developed to classify patients who did and did not develop AF. Premature atrial activity (PAC) was greater in AF patients (P < 0.01). Certain heart rate variability (HRV) and turbulence parameters also differed in patients who did and did not develop AF. In contrast, P-wave morphology was similar in patients with and without AF. Receiver operating curve (ROC) analysis applied to the model produced a C-statistic of 0.904. The model thus correctly classified AF patients with more than a 90% sensitivity and a 70% specificity. Among the 19 ECG parameters analyzed, PAC activity, frequency-domain HRV, and heart rate turbulence parameters were the best discriminators for postoperative AF.