Preoperative History Of Atrial Fibrillation Research Articles

Determinants and impact of postoperative atrial fibrillation burden during 2.5 years of continuous rhythm monitoring after cardiac surgery: Results from the RACE V prospective cohort study

BackgroundEarly postoperative atrial fibrillation (POAF) is common after cardiac surgery and is associated with late-POAF recurrences. However, little is known about the burden of POAF and its potential impact on long-term outcomes after cardiac surgery, particularly on the risk for late-POAF recurrences. ObjectiveThe purpose of this study was to establish the distribution of POAF burden and to determine the association between early-POAF burden and late-POAF recurrences during 2.5 years of continuous rhythm monitoring after cardiac surgery in patients with and without preoperative history of atrial fibrillation (AF). MethodsPatients undergoing cardiac surgery were prospectively enrolled and postoperatively continuously monitored with an implantable loop recorder for 2.5 years. All patients underwent extensive clinical assessment at baseline. During follow-up, all AF episodes were registered, and AF associated metrics, such as burden, were calculated for different time intervals. Early-POAF was defined as AF within first 90 postoperative days and late-POAF as AF after this interval. ResultsA total of 98 consecutive patients were included. POAF burden during the early postoperative phase was significantly higher compared to the late postoperative phase (P <.001). The longest individual POAF episode was strongly associated with increased POAF burden after adjusting for age, sex, and AF history (standardized Beta: 0.91, P <.001). Also, early-POAF burden was associated with late-POAF (re)occurrence after adjusting for age, sex, AF history (adjusted hazard ratio 1.93, 95% confidence interval 1.42–2.62, P <.001). ConclusionPOAF burden was significantly associated with the longest individual POAF episode duration. Additionally, greater early-POAF burden was associated with increased late-POAF incidence, highlighting its potential in estimating the risk for long-term POAF recurrences.

Associations between new-onset postoperative atrial fibrillation and long-term outcome in patients undergoing surgical aortic valve replacement.

Data on prognostic implications of new-onset postoperative atrial fibrillation (POAF) after surgical aortic valve replacement (SAVR) is limited. We sought to explore associations between POAF, early initiated oral anticoagulation (OAC) and long-term outcome after SAVR and combined SAVR + coronary artery bypass grafting (CABG). This is a retrospective, population-based study including all isolated SAVR (n = 7038) and combined SAVR and CABG patients (n = 3854) without a history of preoperative atrial fibrillation (AF) in Sweden 2007-2017. Individual patient data were merged from 4 nationwide registries. Inverse probability of treatment weighting-adjusted Cox regression models were employed separately in SAVR and SAVR + CABG patients. The median follow-up time was 4.7 years (range 0-10 years). POAF occurred in 44.5% and 50.7% of SAVR and SAVR + CABG patients, respectively. In SAVR patients, POAF was associated with increased long-term risk of death [adjusted hazard ratio (aHR) 1.21 (95% confidence interval 1.06-1.37)], ischaemic stroke [aHR 1.32 (1.08-1.59)], any thromboembolism, heart failure hospitalization and recurrent AF. In SAVR + CABG, POAF was associated with death [aHR 1.31 (1.14-1.51)], recurrent AF and heart failure, but not with ischaemic stroke [aHR 1.04 (0.84-1.29)] or thromboembolism. OAC was dispensed within 30 days after discharge to 67.0% and 65.9%, respectively, of SAVR and SAVR + CABG patients with POAF. Early initiated OAC was not associated with reduced risk of death, ischaemic stroke or thromboembolism in any group of patients. POAF after SAVR is associated with an increased risk of long-term mortality and morbidity. Further studies are warranted to clarify the role of OAC in SAVR patients with POAF.

The Impact of Statins on Postdischarge Atrial Fibrillation After Cardiac Surgery: Secondary Analysis from a Randomized Trial

BackgroundWhether statins reliably reduce the risk of postoperative atrial fibrillation (POAF) in patients undergoing cardiac surgery remains controversial. We sought to determine the impact of statin use on new-onset postdischarge POAF in the Post-Surgical Enhanced Monitoring for Cardiac Arrhythmias and Atrial Fibrillation (SEARCH-AF) CardioLink-1 randomized controlled trial. MethodsWe randomized 336 patients with risk factors for stroke (CHA2DS2-VASc score ≥ 2) and no history of preoperative atrial fibrillation (AF) to 30-day continuous cardiac rhythm monitoring after discharge from cardiac surgery with a wearable, patched-based device or to usual care. The primary endpoint was the occurrence of cumulative AF and/or atrial flutter lasting for ≥ 6 minutes detected by continuous monitoring, or AF and/or atrial flutter documented by a 12-lead electrocardiogram within 30 days of randomization. ResultsThe 260 patients (77.4%) discharged on statins were more likely to be male (P = 0.018) and to have lower CHA2DS2-VASc scores (P = 0.011). Patients treated with statins at discharge had a 2-fold lower rate of POAF than those who were not treated with statins in the entire cohort (18.4% vs 8.1%, log-rank P = 0.0076). On multivariable Cox regression including the CHA2DS2-VASc score adjustment, statin use was associated with a lower risk of POAF (hazard ratio 0.43, 95% confidence interval: 0.25-0.98, P = 0.043). Use of statins at a higher intensity was associated with lower risk of POAF, suggestive of a dose–response effect (log-rank Ptrend = 0.0082). ConclusionsThe use of statins was associated with a reduction in postdischarge POAF risk among patients undergoing cardiac surgery. The routine use of high-intensity statin to prevent subacute POAF after discharge deserves further study.

Risk and Subtypes of Stroke Following New-Onset Postoperative Atrial Fibrillationin Coronary Bypass Surgery: APopulation-Based Cohort Study.

Background New-onset postoperative atrial fibrillation (POAF) develops in approximately one-third of patients undergoing cardiac surgery and is associated with a higher incidence of ischemic stroke and increased mortality. However, it remains unknown to what extent ischemic stroke events in patients with POAF are cardioembolic and whether anticoagulant therapy is indicated. We investigated the long-term risk and pathogenesis of postoperative stroke in patients undergoing coronary artery bypass grafting experiencing POAF. Methods and Results This was a register-based cohort study. Data from the WDHR (Western Denmark Heart Registry) were linked with the DNPR (Danish National Patient Register), the Danish National Prescription Register, and the Cause of Death Register. All stroke diagnoses were verified, and ischemic stroke cases were subclassified according to pathogenesis. Furthermore, investigations of all-cause mortality and the use of anticoagulation medicine for the individual patient were performed. A total of 7813 patients without a preoperative history of atrial fibrillation underwent isolated coronary artery bypass grafting between January 1, 2010, and December 31, 2018, in Western Denmark. POAF was registered in 2049 (26.2%) patients, and a postoperative ischemic stroke was registered in 195 (2.5%) of the patients. After adjustment, there was no difference in the risk of ischemic stroke (hazard ratio [HR], 1.08 [95% CI, 0.74-1.56]) or all-cause mortality (HR, 1.09 [95% CI, 0.98-1.23]) between patients who developed POAF and non-POAF patients. Although not statistically significant, patients with POAF had a higher incidence rate (IR; per 1000 patient-years) of cardioembolic stroke (IR, 1 [95% CI, 0.6-1.6] versus IR, 0.5 [95% CI, 0.3-0.8]), whereas non-POAF patients had a higher incidence rate of large-artery occlusion stroke (IR, 1.1 [95% CI, 0.8-1.5] versus IR, 0.7 [95% CI, 0.4-1.4]). Early initiation of anticoagulation medicine was not associated with a lower risk of ischemic stroke. However, patients with POAF were more likely to die of cardiovascular causes than non-POAF patients (P<0.001). Conclusions We found no difference in the adjusted risk of postoperative stroke or all-cause mortality in POAF versus non-POAF patients. Patients with POAF after coronary artery bypass grafting presented with a higher, although not significant, proportion of ischemic strokes of the cardioembolic type.

Impact of diabetes and glucose-lowering therapy on post-operative atrial fibrillation after cardiac surgery: secondary analysis of the SEARCH-AF CardioLink-1 randomized clinical trial

Abstract Background Diabetes mellitus is an important risk factor for atrial fibrillation (AF) and is associated with an increased risk of complications for patients with AF. The impact of diabetes on post-operative AF after cardiac surgery is not well-defined. Purpose We sought to characterize the effect of diabetes, insulin, and oral hypoglycemic agents on the incidence of post-operative atrial fibrillation (POAF) after cardiac surgery. Accordingly, we conducted a secondary analysis of the Post-Surgical Enhanced Monitoring for Cardiac Arrhythmias and Atrial Fibrillation (SEARCH-AF) CardioLink-1 randomized trial. Methods In the SEARCH-AF trial, 336 patients with risk factors for stroke (CHA2DS2-VASc score ≥2) and no history of preoperative AF were randomized to usual care or continuous cardiac rhythm monitoring for 30 days after discharge from cardiac surgery with a wearable, patched-based device. The primary outcome was occurrence of cumulative atrial fibrillation/flutter (AF/AFL) lasting for ≥6 minutes detected by continuous monitoring or AF/AFL documented by a 12-lead electrocardiogram within 30 days of randomization. We assessed the association between diabetes and occurrence of post-operative AF. In addition, we examined the association between POAF and glucose-lowering therapy among patients with diabetes. Results Among the 176 (52%) patients with diabetes in the study cohort, 80 (45%) patients were treated with at least 1 oral hypoglycemic agent and 44 (25%) patients were treated with insulin. The incidence of POAF occurring within 30 days after discharge from surgery was similar between patients with or without diabetes (cumulative incidence: 10.8% vs. 10.0%, log-rank p=0.77). Among patients with diabetes, the incidence of POAF was highest in those who were not treated with glucose-lowering therapy (17.3%) when compared with those treated with oral hypoglycemic agents (10.0%) or insulin (4.5%) (log-rank ptrend=0.045 among the 3 groups). In an exploratory analysis, we observed a trend suggesting a lower incidence of POAF among cardiac surgical patients who were treated with SGLT-2 inhibitors (log-rank ptrend=0.084). Conclusion The incidence of POAF occurring after discharge from cardiac surgery is equally high among patients with or without diabetes. Our results suggest a potential association between specific glucose-lowering therapies and risk of POAF after cardiac surgery, meriting further investigations. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Heart and Stroke Foundation of Canada

New-Onset Atrial Fibrillation in Patients Undergoing Liver Transplantation: Retrospective Analysis of Risk Factors and Outcomes

The authors aimed to identify predictors of new-onset postoperative atrial fibrillation (POAF) during the initial 90 days following liver transplantation, and to assess the association between POAF in-hospital and 1-year mortality. A retrospective cohort study. At a university hospital between 2005 and 2017. Adults without a history of preoperative atrial fibrillation who underwent orthotopicliver transplantation. The authors assessed the univariate association between new-onset of POAF in the postoperative period and each potential factor through a logistic regression model. Moreover, they explored predictors for POAF through stepwise selection. Finally, the authors assessed the relationship between POAF and in-hospital and 1-year mortality using logistic regression models, and whether the duration of atrial fibrillation was associated with in-hospital and 1-year mortality. Among 857 patients, 89 (10.4%) developed POAF. Using only preoperative variables, pulmonary hypertension, age, Model for End-Stage Liver Disease (MELD) score, and White race were identified as the most important predictors. Model discrimination was 0.75 (95% CI: 0.69-0.80), and incorporating intraoperative variables was 0.77 (95% CI: 0.72-0.82). In-hospital mortality was observed in 7.2% (6/83) of patients with new-onset of POAF, and in 2.8% (22/768) without, with confounder-adjusted odds ratio (OR) 1.00 (97.5% CI: 0.29,3.45; p=0.996). One-year mortality was 22.4% (20/89) in patients who developed POAF and 8.3% (64/768) in patients who did not, confounder-adjusted OR 2.64 (97.5% CI: 1.35-5.16; p=0.001). The duration of POAF did not affect long-term postoperative mortality. Preoperative, mostly unmodifiable comorbidities are important risk factors for new-onset POAF after liver transplantation. The POAF was not associated with in-hospital mortality, but with increased 1-year mortality. Once developed, the duration of POAF did not affect long-term mortality after a liver transplant.

Late onset atrial fibrillation in patients undergoing surgical aortic valve replacement.

Aortic valve disease is a risk factor for atrial fibrillation (AF), and AF is associated with increased late mortality and morbidity after cardiac surgery. The evolution of alternative approaches to AF prophylaxis, including less invasive technologies and medical therapies, has altered the balance between risk and potential benefit for prophylactic intervention at the time of surgical aortic valve replacement (SAVR). Such interventions impose incremental risk, however, making an understanding of predictors of new onset AF that persists beyond the perioperative episode relevant. We conducted a retrospective single-institution cohort analysis of patients undergoing SAVR with no history of preoperative AF (n = 1014). These patients were cross-referenced against an institutional electrocardiogram (ECG) database to identify those with ECGs 3-12 months after surgery. Logistic regression was used to identify predictors of late AF. Among the 401 patients (40%), who had ECGs in our institution 3-12 months after surgery, 16 (4%) had late AF. Patients with late AF were older than patients without late AF (73 vs. 65, p = .025), and underwent procedures that were more urgent/emergent (38% vs. 15%, p = .015), with higher predicted risk of mortality (2.2% vs. 1.3%, p = .012). Predictors associated with the development of late AF were advanced age, higher preoperative creatinine level and urgent/emergent surgery. The incidence of late AF 3-12 months after SAVR, is low. Prophylactic AF interventions at the time of SAVR may not be warranted.

Patient-Reported Atrial Fibrillation After Septal Myectomy for Hypertrophic Cardiomyopathy

BackgroundPatient-reported outcomes are important metrics of medical and surgical care. In this study, we investigated the prevalence and risk factors of patient-reported postdischarge atrial fibrillation (AF) after septal myectomy for obstructive hypertrophic cardiomyopathy. MethodsPatients undergoing transaortic septal myectomy from August 2001 to January 2017 were contacted regarding postdischarge AF through questionnaire-based surveys sent at 3, 5, and 10 years post procedure. For each patient, the most recent survey response was analyzed. ResultsAmong 949 patients, 248 (26.1%) last responded at 3 years post procedure, 353 (37.2%) at 5 years, and 348 (36.7%) at 10 years. The overall incidence of patient-reported postdischarge AF was 34.4% (n = 326), and at 3, 5, and 10 years, the incidences were 22.2%, 34.8%, and 42.5% (P < .001). After multivariable adjustment, history of preoperative AF (odds ratio [OR] 5.566, P < .001), early postoperative AF within the first 30 days (OR 2.211, P < .001), preoperative left atrial volume index (OR 1.014, P = .005), postoperative right ventricular systolic pressure (OR 1.021, P = .013), postoperative moderate or greater mitral valve regurgitation (OR 1.893, P = .022), and preoperative septal thickness (OR 1.043, P = .036) were independently associated with patient-reported postdischarge AF. ConclusionsThe incidence of patient-reported postdischarge AF increases with increasing length of follow-up after septal myectomy. We identified several risk factors for late postdischarge AF that were associated with chronicity of left ventricular outflow tract obstruction, and earlier intervention may mitigate late atrial arrhythmias.

Impact of atrial fibrillation and biventricular pacing percentage on long-term outcome in patients with heart failure treated with cardiac resynchronization therapy

Abstract Introduction A history of preoperative atrial fibrillation (AF) has been found to be associated with unfavorable outcomes, higher risks of non-response to cardiac resynchronization therapy (CRT) and loss of biventricular pacing (BivP). We aimed to assess the impact of AF and BivP on long-term outcomes in heart failure patients treated with CRT. Methods We retrospectively enrolled 227 patients undergoing CRT implantation between 2013 and 2020 according to the current guidelines. 118 patients were included in our analysis, from whom all data were available. Clinical, electrocardiographic and echocardiographic parameters were evaluated at baseline and 6 months after CRT. Response to CRT was defined as an increase in left ventricular ejection fraction (LVEF) &amp;gt;10%. We considered an effective delivery of BivP &amp;gt;98%. The primary endpoint was the composite endpoint of hospitalization due to HF or death for any cause. Results 118 patients were included (mean age 69±11 years, 66.1% males, 39.8% ischemic etiology; baseline LVEF was 27,6±6%). Patients were divided into AF (n=42; 35,6%) and sinus rhythm (SR (n=76); 18 patients had permanent AF. AF patients had higher index left atrial volume and left ventricular mass (p&amp;lt;0.001). Mean follow-up time was 43±18 months. BivP percentage was significantly superior in SR than in AF patients (98.1±2.1% vs 94.7±4.5%, p&amp;lt;0.001), with 75% of SR patients having BivP&amp;gt;98% vs 30,3% of AF patients (p&amp;lt;0.001). There were no differences in preoperative parameters between them. The response rate to CRT was higher in SR patients when compared to AF patients (63,2% vs 40,5%, p=0.021). Indeed, the variation of LVEF was higher in SR patients (12±10% vs 7±9%, p=0.012). During follow-up, there were significant differences between AF and SR patients in the primary endpoint (73,8% vs 42,6%, p&amp;lt;0.001), and mortality for any cause (26,2% vs 9,2% p=0.014; p&amp;lt;0.001). In a multivariate logistic regression analysis pre-procedural AF and BivP (%) were the only independent predictors of primary endpoint (HR 8.949, 95% CI 2.429 – 32.972, p=0.001; HR 0.719, 95% CI 0.526 – 0.982, p=0.038, respectively). Kaplan-Meier curves showed that event survival free was higher in SR patients when compared to AF (69±4 vs 24±3 months, p&amp;lt;0.001) Conclusion Pre - procedural AF and BivP are independent predictors of the occurrence of a primary endpoint of hospitalization due to HF or death for any cause in HF patients submitted to CRT. Funding Acknowledgement Type of funding sources: None.

Perioperative risk factors for new-onset postoperative atrial fibrillation among patients after isolated coronary artery bypass grafting: A retrospective study.

Incidence of atrial fibrillation is considerably high after open heart surgery, which may prolong hospitalization and increase mortality. The aim of the present study is to investigate the perioperative risk factors for the occurrence of new-onset atrial fibrillation following isolated coronary artery bypass grafting. A retrospective study. A total of 327Korean patients recorded to have undergone first-time isolated coronary artery bypass grafting and no preoperative history of atrial fibrillation were included. The data were obtained from electronic health record from January 2010 to December 2019 at a tertiary care hospital. Predictors of new-onset atrial fibrillation after the surgery were identified by multivariate logistic regression analysis. The incidence rate of new-onset atrial fibrillation after coronary artery bypass grafting was approximately 28.4%, and the highest occurrence rate was 44.1% on postoperative day 2. Our main finding showed that advanced age was the strongest predictor of atrial fibrillation after coronary artery bypass grafting. In addition, history of stroke and depression, chronic obstructive pulmonary disease and intraoperative use of intra-aortic balloon pump were shown to be the risk factors. Our findings showed that approximately 28% patients had new-onset atrial fibrillation after the surgery. Healthcare professionals should proactively assess risk factors for postoperative atrial fibrillation and focus more on older adults with pre-existing comorbidities, such as stroke, depression and chronic obstructive pulmonary disease. Older adults with history of stroke, depression and comorbid chronic obstructive pulmonary disease should be carefully monitored closely during perioperative period. The study highlights that early assessment of new-onset postoperative atrial fibrillation can contribute to promote the quality of nursing care and frontline nurses may be a vital role in timely detection of atrial fibrillation after surgery. Prospective studies are required to identify the mechanisms connecting perioperative risk factors for atrial fibrillation after cardiac surgery.

Abstract 17255: Premature Atrial Stimulation Reveals Increased Conduction Slowing and Block in Cardiac Surgery Patients That Develop Postoperative Atrial Fibrillation

Introduction: Postoperative atrial fibrillation (POAF) is a common cardiac surgery complication that is highly associated with increased morbidity and mortality. The relation of presurgical left atrial (LA) conduction abnormalities and POAF during intraoperative premature atrial stimulation (S1S2) pacing is investigated and reported. Hypothesis: Intraoperative premature atrial stimulation reveals increased areas of slowed or blocked conduction in patients that develop POAF. Methods: High-density intraoperative epicardial mapping was conducted in 20 cardiac surgery patients with no history of preoperative atrial fibrillation (AF) both in sinus rhythm (SR) and during S1S2 pacing. A flexible array comprised of 240 electrodes was placed on the posterior LA wall in between the pulmonary veins. For each patient, the area of conduction block (CB), conduction delay (CD) and combined conduction delay and block (CDCB) for conduction velocity &lt;0.1 m/s, 0.1 - 0.2 m/s and &lt;0.2 m/s, respectively were quantified. Results: In 20 patients, 6 (30%) developed POAF. As shown in the Figure, conduction maps revealed the presence of significantly higher areas of CD (13.2±6.6% vs. 6.1±4.2%, p=0.03) and CDCB (17.5±8.7% vs. 7.4±6.4%, p=0.03), and a trend toward larger CB (4.2±3.8% vs. 1.3±2.9%, p=0.09) in patients that developed POAF for premature atrial beat S2 compared to patients that remained in SR after cardiac surgery. S1 paced beats and SR did not show significant differences in abnormal conduction percentages between patients with and without POAF. Conclusions: Premature atrial stimulation accentuates conduction abnormalities in cardiac surgery patients that develop POAF, revealing a pre-surgical substrate that may indicate greater risk for post-surgical atrial arrhythmias.

Vitamin K antagonists versus direct oral anticoagulants after cardiac surgery: a 31-country cohort study

Abstract Background About 10% of patients undergoing cardiac surgery have a history of atrial fibrillation (AF). Among these patients, uncertainty exists regarding the safest and most effective oral anticoagulant (OAC) during the postoperative period. Purpose To evaluate practice patterns regarding OAC early after cardiac surgery in patients with a preoperative history of AF and to compare the safety and effectiveness of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs). Methods We conducted a nested cohort study within the Left Atrial Appendage Occlusion Study (LAAOS) III (NCT01561651). LAAOS III included patients with AF undergoing cardiac surgery with a CHA2DS2-VASC ≥2. In this substudy, we examined patients without end-stage renal dysfunction (eGFR &amp;gt;30 mL/min/1.73m2) who were discharged on OAC. We evaluated bleeding and thromboembolism within 90 days postoperatively using logistic regression adjusting for CHA2DS2-VASC score. Results Recruitment started in 2012 and completed in 2018 in 113 centres in 31 countries. Of the 4811 patients enrolled in LAAOS III, 3725 (77%) were included in this substudy. Preoperatively, 58% of patients received OAC: 56% DOACs and 44% VKAs. At hospital discharge 23% received DOACs and 77% VKAs; 55% of patients on a DOAC at baseline were switched to a VKA while 5% of patients on a VKA were switched to a DOAC. Patients discharged on a DOAC were older, had a higher CHA2DS2-VASC, and were more likely to be male. Patients having undergone an isolated coronary bypass procedure were more likely prescribed DOACs than VKAs (41% vs 23%, p&amp;lt;0.001) whereas isolated non-mechanical valve patients were more likely to be prescribed VKAs (43% vs 28%, p&amp;lt;0.001). Switching from a DOAC to a VKA postoperatively occurred in 42% of patients In Australia/New Zealand, 49% in Europe, and 63% in North America. Major bleeding between 48 hours postoperatively and 30 days occurred in 1.5% in the DOAC group and 1.3% in the VKA group (aOR 1.14, 95% CI 0.60–2.15, p=0.69) while between 48 hours and 90 days, it occurred in 1.8% of patients in both groups (aOR 0.97, 95% CI, 0.54–1.17, p=0.91). Cardiac tamponade, the composite of stroke and systemic arterial embolism, and the composite of stroke, systemic arterial embolism and death did not differ significantly at 30 and 90 days between the DOAC and VKA groups. Conclusions VKAs was the dominant OAC used early after cardiac surgery, but postoperative OAC practices varied by region. After adjustment for CHA2DS2-VASC score, the early postoperative incidence of major bleeding and of the composite of stroke and systemic arterial embolism did not differ significantly when DOACs were compared with VKAs. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): CIHR, Heart and Stroke Foundation

Ablation of atrial fibrillation during coronary artery bypass grafting: Late outcomes in a Medicare population

BackgroundThis study compares outcomes of patients with preoperative atrial fibrillation undergoing coronary artery bypass grafting (CABG) with or without concomitant atrial fibrillation ablation in a nationally representative Medicare cohort. ObjectivesThis study examined early and late outcomes in CABG patients with a preoperative history of atrial fibrillation to determine the correlation between surgical atrial fibrillation ablation to mortality and stroke or systemic embolization. MethodsIn the Medicare-linked Society of Thoracic Surgeons database, 361,138 patients underwent isolated CABG from 2006 to 2013; 34,600 (9.6%) had preoperative atrial fibrillation; 10,541 (30.5%) were treated with surgical ablation (ablation group), and 23,059 were not (no ablation group). Propensity score matching was performed using a hierarchical mixed model. Long-term survival was summarized using Kaplan-Meier curves and Cox regression models with robust variance estimation. The stroke or systemic embolization incidence was modeled using the Fine-Gray model. Median follow-up was 4 years. ResultsLong-term mortality in propensity score-matched CABG patients (mean age 74 years; Society of Thoracic Surgeons risk score, 2.25) receiving ablation versus no ablation was similar (log-rank P = .30). Stroke or systemic embolization occurred in 2.2% versus 2.1% at 30 days and 9.9% versus 12.0% at 5 years (Gray P = .0091). Landmark analysis from 2 to 5 years showed lower mortality (hazard ratio, 0.89; 95% confidence interval 0.82-0.97; P = .0358) and lower risk of stroke or systemic embolization (hazard ratio, 0.73; 95% confidence interval, 0.61-0.87; P = .0006) in the ablation group. ConclusionsConcomitant ablation in CABG patients with preoperative atrial fibrillation is associated with lower stroke or systemic embolization and mortality in patients who survive more than 2 years.

Preoperative predictors of new-onset prolonged atrial fibrillation after surgical aortic valve replacement

ObjectivePatients undergoing surgical aortic valve replacement (SAVR) are at risk of developing prolonged atrial fibrillation (AF) after surgery. Prophylactic interventions such as left atrial appendage amputation (LAAA) and pulmonary vein isolation (PVI) impose cost and operative risk, discouraging routine use. To guide such interventions, we investigated preoperative predictors of AF. MethodsA retrospective analysis was performed on patients undergoing SAVR between 2011 and 2017. Patients were excluded if they had a preoperative history of AF or underwent a LAAA or PVI. Baseline characteristics were compared between those who did and did not develop prolonged postoperative AF. Predictors of prolonged AF were identified using multivariable logistic regression. ResultsOf 720 patients identified, 170 (25%) developed prolonged (beyond 30 days) AF. Compared with patients who did not develop AF, those who developed prolonged AF were older (70.1 vs 62.4 years, P < .001), had a greater incidence of hypertension (78% vs 61%, P < .001), and were less likely to smoke (16% vs 31%, P < .01). On multivariable regression, older age (odds ratio, 1.05; P < .01) and left atrial enlargement (odds ratio, 1.66; P = .04) were predictors of prolonged AF. In this high-risk cohort, the incidence of prolonged postoperative AF was 40%. ConclusionsOlder age and left atrial enlargement identify a stratum of patients at high risk of developing prolonged postoperative AF after SAVR. Multicenter, prospective studies should investigate the value of prophylactic interventions such as LAAA, Cox maze, or PVI in these individuals to obviate the consideration of late anticoagulation.

The effect of mitral valve replacement on atrial fibrillation behaviour

Background: Atrial fibrillation (AF) persisting after mitral valve surgery reduces survival due to heart failure and thrombo-embolisms and impairs quality of life. Restoration of the sinus rhythm might lead to a lower incidence of thrombo-embolism and valve-related complications in the postoperative period.Methods: This non-randomized prospective study was carried out between period April 2015 to December 2018 in the Department of Cardiothoracic and Vascular Surgery, Government General hospital, Guntur, Andhra Pradesh, India. A total of 80 patients underwent mitral valve replacement during the study period. 50 patients out of these were with atrial fibrillation and were part of this study, who underwent mitral valve replacement.Results: All fifty patients were in atrial fibrillation based on clinical examination and the echocardiogram. 13 patients preoperatively were in atrial fibrillation with fast ventricular rate. These patients were placed on antiarrhythmic drugs to control the ventricular rate prior to mitral valve replacement. After surgery twenty out of fifty (40%) patients reverted to NSR and maintained the same rhythm till the 6 months of follow-up. Twenty-nine (58%) patients continued in atrial fibrillation after surgery.Conclusions: The results of the present study showed that preoperative atrial rhythm strongly determines postoperative rhythm. In view of the promising results of combined mitral valve and anti-atrial fibrillation surgery, the inescapable conclusion is that the anti-arrhythmic procedure should be offered routinely to all patients with a history of preoperative AF.

Storage time of intraoperative transfused allogeneic red blood cells is not associated with new-onset postoperative atrial fibrillation in cardiac surgery.

BackgroundAllogeneic red blood cell (RBC) transfusion has been associated with new-onset postoperative atrial fibrillation (POAF) following cardiac surgery. Prolonged storage time of RBC may increase the risk. The primary aim of the study was to evaluate whether the storage time of RBC is associated with development of POAF.Materials and methodsPre-, per- and postoperative data were retrieved from the Western Denmark Heart Registry and local blood banks regarding patients who underwent coronary artery bypass surgery, valve surgery or combined procedures in Aalborg or Aarhus University Hospital during 2010–2014. Multiple logistic regression was used to determine the risk of POAF according to transfusion of RBC on the day of surgery. Furthermore, we determined trend in storage time of RBC according to risk of POAF using restricted cubic splines. Patients with a history of preoperative atrial fibrillation, patients who received transfusions preoperative and patients who died at the day of surgery were among excluded patients.ResultsA total of 2,978 patients with a mean age of 66.4 years were included and 609 patients (21%) received RBC transfusion on the day of surgery. POAF developed in 752 patients (25%) and transfused patients were at an increased risk compared with non-transfused patients (adjusted Odds Ratios for patients receiving RBC: 1.37; 95% CI: 1.11–1.69, P-value = 0.004). However, RBC transfusion was not necessarily the cause of POAF and may only be a marker for development of POAF. There was no significant association between storage time of RBC and POAF.ConclusionsIn contrast to intraoperative allogeneic RBC transfusion in general, increased storage time of RBC is not associated with development of POAF in cardiac surgery.

Duodenal ulcers are a major cause of gastrointestinal bleeding after cardiac surgery

ObjectiveTo determine the incidence of gastrointestinal (GI) bleeding in patients after cardiac surgery, assess the perioperative risk factors, and determine the type of GI tract pathology associated with bleeding events. MethodsAt a tertiary referral hospital, all cardiac surgery patients having a postoperative GI bleed from April 2002 to March 2012 were identified. To determine bleeding etiology, only patients requiring endoscopy were included in the analysis. By retrospective review of 3 prospectively maintained databases, the incidence and independent predictors of GI bleeding, as well as endoscopic findings, were determined. ResultsNinety-one GI bleeding events that required endoscopy were identified in 9017 patients. Those that bled were aged 71 ± 12 years, and 76% were men. Sixty-three percent of these patients had valve surgery and 37% had an isolated coronary artery bypass grafting. The overall incidence of GI bleeding was 1.01%, with an upper GI source accounting for 78%. Endoscopy data found a duodenal ulcer as the bleeding source in 71%, whereas stress gastritis accounted for 8%. Preoperative risk factors for bleeding included age ≥70 years, ejection fraction <35%, congestive heart failure, cerebrovascular disease, chronic kidney disease, and gastrointestinal disease. A preoperative history of atrial fibrillation and anticoagulation with Coumadin also was associated with bleeding. Patients that bled had a 30-day mortality rate of 8.8%, which was significantly greater than patients who did not bleed (4.3%; P = .03). ConclusionsClinical variables can be used to identify patients at high risk for GI bleeding after cardiac surgery. When GI bleeding occurs, the most common cause is duodenal ulceration, which has an association with Helicobacter pylori infection. These findings may provide an opportunity to initiate preoperative preventative strategies.

Pentraxin 3 and other inflammatory biomarkers related to atrial fibrillation in cardiac surgery.

The aim was to evaluate the association between perioperative inflammatory biomarkers and atrial fibrillation (AF) in cardiac surgical patients. Forty-two patients undergoing cardiac surgery were divided into three groups according to the occurrence of AF: Group A (n = 22) - patients with no AF, Group B (n = 11) - patients with new onset AF postoperatively and Group C (n = 9) - patients with preoperative history of atrial fibrillation. The serum levels of PTX3, CRP, TLR2, IL-8, IL-18, sFas, MMP-7 and MMP-8 were measured at the following time points: before surgery, immediately and 6 h after surgery and on the 1st, 3rd and 7th postoperative days (POD). Serum levels of PTX3 showed a significant difference between Groups A and C on the 3rd POD (p<0.05) and on the 7th POD (p<0.0001). IL-8 levels were different between Groups A and C immediately after surgery (p<0.05), 6 hours after surgery (p<0.05) and on the 3rd POD (p<0.05). There was a difference between Groups B and C on the 1st POD in IL-8 levels (p<0.05). The sFas levels differed between Groups A and C on the 3rd POD (p<0.01) and the 7th POD (p<0.05). There was also a difference on the 7th POD (p<0.05) between the Groups B and C. No significant differences between the groups was seen for other biomarkers. This study demonstrates significantly different dynamics of PTX3, IL-8 and sFas levels after cardiac surgery in relation to AF.

Predicting early left ventricular dysfunction after mitral valve reconstruction: The effect of atrial fibrillation and pulmonary hypertension

The preoperative ejection fraction (EF) and left ventricular (LV) end-systolic dimension are known predictors of postoperative LV dysfunction after mitral valve repair. We investigated the effect of a preoperative history of atrial fibrillation and moderate pulmonary hypertension (defined as pulmonary artery systolic pressure >50 mm Hg) on early postoperative LV dysfunction. From 2003 to 2010, 632 patients who had undergone successful mitral valve repair surgery for degenerative disease were included in the present study. The preoperative and postoperative echocardiographic data and postoperative outcomes were collected retrospectively. We analyzed the demographic, hemodynamic, and echocardiographic parameters to assess the predictors of early postoperative LV dysfunction, defined as an LVEF <50%. The mean age of the cohort was 57 ± 13 years. All patients had less than mild mitral regurgitation onpostoperative echocardiography. After mitral valve repair, a significant decrease in the LVEF (60% ± 8% to 54% ± 9%), LV end-systolic diameter (36 ± 7 mm to 33 ± 7 mm), and LV end-diastolic dimension (56± 8 mm to 48 ± 7 mm) was observed at early postoperative echocardiography (P<.001). On multivariate regression analysis, preoperative atrial fibrillation, pulmonary hypertension, and LV end-systolic dimension were independent predictors of the postoperative LVEF (P=.035 and P<.001, respectively). Preoperative atrial fibrillation (odds ratio, 1.97; 95% confidence interval, 1.28-3.02; P=.002) and pulmonary artery systolic pressure >50 mm Hg (odds ratio, 1.82; 95% confidence interval, 1.11-2.97; P=.017) increased the risk of postoperative LV dysfunction by almost twofold. In addition to the established predictors of postoperative LV dysfunction, the presence of preoperative pulmonary hypertension and a history of atrial fibrillation in patients undergoing mitral valve repair surgery increased the risk of early postoperative LV dysfunction by almost twofold.

Preoperative serum levels of interleukin-6 and interleukin-8 as predictors of the development of postoperative atrial fibrillation among patients undergoing coronary artery bypass grafting surgery

Objectives The aim of the study was to evaluate the ability of preoperative estimation of serum interleukins (IL-6 and IL-8) for predicting the possibility of development of postoperative atrial fibrillation (POAF) among patients who have undergone coronary artery bypass grafting (CABG) surgery. Patients and methods The study included 90 patients who underwent CABG, with a mean age of 63.8 ± 4.7 years. All patients underwent on-pump surgery with a mean aortic cross-clamping time of 65.9 ± 14.6 min and a mean cardiopulmonary bypass (CPB) time of 99.1 ± 19.7 min. Preoperative blood samples were collected for enzyme-linked immunosorbent assay estimation of serum IL-6 and IL-8 levels. Results After CABG surgery, 24 patients developed POAF (26.7%); five were female and 19 were male with a mean age of 64.1 ± 5.2 years. Four patients had a history of previous atrial fibrillation (AF), whereas 20 patients had no history of preoperative AF. Mean aortic clamping and CPB times were significantly longer in POAF patients compared with AF-free patients. Mean preoperative serum IL-6 and IL-8 levels were significantly higher in patients compared with controls, with significantly higher levels in POAF patients compared with AF-free patients. There was a positive significant correlation between the occurrence of POAF and history of preoperative AF, preoperative serum levels of IL-6 and IL-8, and aortic clamping and CPB times. Regression analysis defined elevated serum levels of IL-6 and IL-8, prolonged aortic clamping and CPB times, and history of preoperative AF as predictors of the occurrence of POAF among patients undergoing CABG in decreasing order of significance. Conclusion Inflammatory factors play a prominent role in the pathogenesis of POAF; high preoperative serum levels of IL-6 and IL-8 could aid in identification of patients liable to develop POAF, especially when associated with prolonged clamping time or preoperative history of AF.