Incidence Of New-onset Postoperative Atrial Fibrillation Research Articles

Development and validation a nomogram for predicting new-onset postoperative atrial fibrillation following pulmonary resection

BackgroundThe new-onset postoperative atrial fibrillation (NOPAF) following pulmonary resection is a common clinical concern. The aim of this study was to construct a nomogram to intuitively predict the risk of NOPAF and offered protective treatments.MethodsPatients who underwent pulmonary resection between January 2018 and December 2020 were consecutively enrolled. Forward stepwise multivariable logistic regression analyses were used to screen independent predictors, and a derived nomogram model was built. The model performance was evaluated in terms of calibration, discrimination and clinical utility and validated with bootstrap resampling.ResultsA total of 3583 patients who met the research criteria were recruited for this study. The incidence of NOPAF was 1.507% (54/3583). A nomogram, composed of five independent predictors, namely age, admission heart rate, extent of resection, laterality, percent maximum ventilation volume per minute (%MVV), was constructed. The concordance index (C-index) was 0.811. The nomogram showed substantial discriminative ability, with an area under the receiver operating characteristic curve of 0.811 (95% CI 0.758-0.864). Moreover, the model shows prominent calibration performance and higher net clinical benefits.ConclusionWe developed a novel nomogram that can predict the risk of NOPAF following pulmonary resection, which may assist clinicians predict the individual probability of NOPAF and perform available prophylaxis. By using bootstrap resampling for validation, the optimal discrimination and calibration were demonstrated, indicating that the nomogram may have clinical practicality.

New-onset postoperative atrial fibrillation after aortic valve replacement: Effect on long-term survival

ObjectiveThere is a paucity of data on long-term survival of new-onset postoperative atrial fibrillation (POAF) after cardiac surgery. Also, mean follow-up in previous studies is confined to a maximum of one decade. This retrospective, longitudinal cohort study was performed to determine the effect on long-term survival of new-onset POAF after aortic valve replacement (AVR) over a mean follow-up of almost 2 decades. MethodsKaplan-Meier survival analysis was used to determine long-term survival after AVR, performed between January 1, 1990, and January 1, 1994, in 569 consecutive patients without a history of atrial fibrillation, divided into 241 patients (42.4%) with and 328 patients (57.6%) without new-onset POAF. New-onset POAF was considered in multivariable analysis for decreased long-term survival. After AVR, patients with new-onset POAF were treated with the aim to restore sinus rhythm within 24 to 48 hours from onset by medication and when medication failed by direct-current cardioversion before discharge home. ResultsMean follow-up after AVR was 17.8 ± 1.9 years. Incidence of new-onset POAF was 42.4%. Kaplan-Meier overall cumulative survival rates at 15 years of follow-up were similar in the patients with new-onset POAF versus those without: 41.5% (95% confidence interval [CI], 35.2-47.7) versus 41.3% (95% CI, 36.0-46.7), respectively. New-onset POAF was not an independent risk factor for decreased long-term survival (hazard ratio 0.815; 95% CI, 0.663-1.001; P = .052). ConclusionsNew-onset POAF after AVR does not affect long-term survival when treatment is aimed to restore sinus rhythm before discharge home.

High Risk for OSA: An Independent Risk Factor for Development of New-Onset Atrial Fibrillation After Cardiac Surgery

SESSION TITLE: Sleep Disorders 1 SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM PURPOSE: New-onset postoperative atrial fibrillation (POAF) is a highly prevalent complication after cardiac surgery with substantial effects on outcomes. Previous studies have reported that obstructive sleep apnea (OSA) is a risk factor for POAF after cardiac surgery. However, it is unknown whether the high risk for developing OSA but yet undiagnosed OSA also increases the risk of POAF. METHODS: We retrospectively analyzed the association between high-risk undiagnosed OSA and the incidence of new-onset POAF in a total of 209 patients who underwent coronary artery bypass grafting surgery with or without concomitant valvular surgery in our university-affiliated community hospital from 2013-2015. After IRB approval, baseline demographics and perioperative characteristics were obtained and study cohort divided into low, high risk and diagnosed cases of OSA. High-risk for OSA defined by presence of 3 or more criteria out of age >65 years, hypertension, presence of snoring, body mass index ≥35 kg/m2 and Mallampatti score ≥3. A primary study outcome was new onset POAF, with secondary outcomes were in-hospital mortality, postoperative length of stay (LOS) and cost of hospitalization. Statistical analysis was performed by SAS 9.4 software with chi-square and Wilcoxon rank sum tests. A multivariate logistic model was developed for predictors of new onset POAF. RESULTS: Out of 209 patients, 39 (18.7%) were high risk, 139 (66.5%) were low risk and 31 (14.8%) were diagnosed cases of OSA. New onset POAF occurred in 96 (45.9%) patients. In the overall population, median age was 67, with 73.2%, 92.8%, and 44.5% were males, whites and obese, respectively. 84.7%, 69.9%, 41.2%, 16.3% and 16.3% had hypertension, coronary artery disease, diabetes, thyroid disorders, and previous history of cardiac surgery, respectively. New onset POAF developed in high vs diagnosed vs low risk for OSA (69.2% vs 41.9% vs 40.3%, p=0.0052). New onset POAF may increases in-hospital mortality (2.1% vs1.8%, p=NS), significantly increases postoperative LOS (8 vs 7 days, p=0.002) and cost ($217810 vs $197527, p=0.024) as compared to no POAF group. Multivariate analysis showed high-risk group had significantly increased risk for new onset POAF as compared to the low-risk group even after adjusting for age, sex, race, smoking status, comorbidities, perioperative variables and previous history and type of cardiac surgery (Odds ratio, 95% CI, 2.6 (1.03, 6.61), p=0.04). CONCLUSIONS: This study demonstrates that high risk for OSA is an independent risk factor for the occurrence of new onset POAF in patients following cardiac surgery and increases the risk by two times as compared to the low risk for OSA. New onset POAF significantly increases postoperative LOS and hospitalization cost after cardiac surgery. Further studies should be performed to validate these findings. CLINICAL IMPLICATIONS: Proper pre-operative screening work-up should be performed in suspected and high-risk cases of OSA and complications can be avoided if new onset POAF be anticipated in such patients and managed accordingly. For reduction of incidence of new onset POAF and its outcomes, high risk for yet undiagnosed OSA patients should be managed similarly as diagnosed OSA patients. DISCLOSURE: The following authors have nothing to disclose: Samir Patel, Rafael Rodriguez, Harmeet Gill, Ajai Rajabalan, Palak Patel, Tejwant Singh, Manuel Bautista No Product/Research Disclosure Information

Association of Body Mass Index With New-Onset Atrial Fibrillation After Coronary Artery Bypass Grafting Operations

Postoperative atrial fibrillation (AF) frequently complicates coronary artery bypass grafting (CABG) operations. As the frequency of obesity has increased in the United States, the number of obese patients undergoing CABG has kept pace. This study sought to define the association between body mass index (BMI) and postoperative AF. We studied 12,367 consecutive patients with no history of AF who underwent isolated CABG operations. BMI was stratified according to Centers for Disease Control and Prevention criteria, and differences in baseline clinical and operative characteristics were adjusted through multivariate logistic regression models. The unadjusted incidence of new-onset postoperative AF demonstrated a U-shape with regard to BMI. The highest incidence (34%) was found in the "lean" stratum (BMI<18.5 kg/m2), followed by 32% in the "severely obese" (BMI≥40 kg/m2) stratum. Lower incidences were found in the "normal" stratum (30%), in the "obese" stratum (28%), and the lowest incidence (26%) was in the overweight stratum. Observed incidence was 50% greater than the expected incidence in the "severely obese" stratum (32% vs 21%). In multivariate regression analysis adjusted for age and other covariates, BMI remains a strong risk factor for new-onset postoperative AF. Compared with normal BMI, obesity (odds ratio, 1.24; 95% confidence interval, 1.08 to 1.42) and severe obesity (odds ratio, 2.00; 95% confidence interval, 1.54 to 2.57) both emerged as strong risk factors for postoperative AF. No association was found between a lean BMI and postoperative AF (odds ratio, 1.14; 95% confidence interval, 0.66 to 1.98). After adjusting for potential confounders, obesity, as reflected by the body mass index, remains an independent predictor of postoperative AF.

New-Onset Postoperative Atrial Fibrillation and Long-Term Survival After Aortic Valve Replacement Surgery

Atrial fibrillation (AF) is recognized as a common complication of open cardiac surgery, occurring in up to 65% of patients. The advancing age and increasing risk profile of patients receiving aortic valve replacement (AVR) surgery is expected to raise incidence of new-onset postoperative AF resulting in potentially higher risk of adverse outcomes. In the early postoperative course, new-onset post-AVR AF is considered relatively easy to treat and is believed to have little impact on patients' long-term outcome. However, the effect of new-onset post-AVR AF on long-term survival is unclear. Survival was assessed in 1,039 consecutive patients without preoperative AF who underwent AVR with or without simultaneous coronary artery bypass graft at Baylor University Medical Center, Dallas, Texas between January 1, 1997 and December 31, 2006. Ten-year unadjusted survival was 50.8% for patients with new-onset postoperative AF and 59.4% for patients without. A propensity-adjusted model controlling for risk factors identified by the Society of Thoracic Surgeons and other clinical-nonclinical details was used to investigate the association between new-onset AF post-AVR and survival. After adjustment, new-onset AF post-AVR was significantly associated with increased risk of death (hazard ratio: 1.48; 95% confidence interval 1.12 to 1.96). This study provides evidence that new-onset post-AVR AF is significantly associated with increased long-term risk of mortality independent of the preoperative severity of disease. After controlling for a comprehensive array of risk factors associated with post-AVR adverse outcomes, risk of long-term mortality in patients who developed new-onset post-AVR AF was 48% higher than in patients without it.

Reduced Postoperative Atrial Fibrillation Using Multidrug Prophylaxis

Atrial fibrillation (AFIB) is the most common complication following coronary artery bypass grafting (CABG). Despite three decades of recognition, efforts to reduce the high incidence reported (15%-30%) have been largely unsuccessful. Reasons for postoperative AFIB are likely multifactorial. As a result, we defined a multidrug prophylaxis based on agents known to be individually effective. This method was applied prospectively to a series of consecutive CABG patients with the goal of reducing the incidence of new-onset postoperative AFIB. Isolated CABG with cardiopulmonary bypass was performed on 517 consecutive patients. A rapid recovery protocol emphasizing AFIB multidrug prophylaxis was applied to all patients. All patients received 10 microg of triiodothyronine intraoperatively when the clamp on the aorta was released. Immediately following CABG, parenteral magnesium was administered to assure a serum magnesium > 2.2 mEq/dL. Thyroxine 200 microg was administered parenterally to all patients on postoperative days 1 and 2. Metoprolol (25 mg to 100 mg/day) was begun on all patients after extubation provided: heart rate > 85 beats/min and systolic blood pressure > 130 mmHg. Parenteral procainamide (12 mg/kg) loading dose, followed by a maintenance dose (2 mg/min), was used for patients who developed premature atrial contractions (> 1/min), nonsustained supraventricular tachycardia, or any episodes of atrial fibrillation. All patients also received postoperative digitalization, steroids, and aggressive diuresis. The 30-day operative mortality was 3.7%. The overall incidence of new-onset postoperative AFIB was 10.3% (53 patients). There was no major difference in operative mortality (7.5% vs 3.2%, p = 0.23), Parsonnet risk score, or intraoperative variables between AFIB patients and the non-AFIB patients. Patients presenting with a preoperative acute myocardial infarction (p < 0.05), left main stenosis > or = 70% (p < 0.01), and advanced age > or = 70 years (p < 0.05) were at increased risk of developing AFIB. The length of stay for patients with AFIB was 9.9 +/- 9.6 days versus 5.9 +/- 5.2 days (p < 0.001). Application of a multidrug prophylaxis can reduce postoperative AFIB to a low incidence. Identification of associated clinical features can help predict patients at risk for postoperative AFIB. Additional strategies to target postoperative AFIB may include treatment at the earliest recognition of atrial rhythm instability.

Middle-aged men with increased waist circumference and elevated C-reactive protein level are at higher risk for postoperative atrial fibrillation following coronary artery bypass grafting surgery

We recently demonstrated that metabolic syndrome (MetS) is an independent risk factor for postoperative atrial fibrillation (POAF) following coronary artery bypass grafting (CABG). In the present work, we sought to determine which feature of the MetS is associated with POAF. We retrospectively analysed the association between metabolic features and the incidence of new-onset POAF in a total of 2214 male patients <65 years who underwent first isolated CABG. Anthropometric data including waist circumference (WC) and complete preoperative lipid profile were available. We also conducted a nested case-control substudy including 147 patients who developed POAF, and were matched for age with a control population. In these patients, C-reactive protein, interleukin-6 (IL-6), and thiobarbituric acid-reactive substances (TBARS; evaluating the oxidative stress) blood levels were determined. In the whole cohort, 19.6% of patients developed POAF. On univariate analysis, body mass index (BMI; P = 0.002) and WC (P = 0.001) were the only anthropometric variables significantly associated with increased incidence of POAF. In the multivariable logistic model, the only independent predictors of POAF were a WC > 102 cm [odds ratio (OR) = 1.40, P = 0.04)] and older age (OR = 1.08, P < 0.001). In the nested case-control substudy C-reactive protein, IL-6, and TBARS levels were not significantly different in patients with or without POAF. Of particular significance, patients with elevated WC > 102 cm and C-reactive protein > 1.5 mg/L or IL-6 >2.2 pg/mL were at a high risk of developing POAF (respectively, OR = 2.32, P = 0.02 and OR = 2.27, P = 0.03). Patients with increased WC combined with elevated C-reactive protein levels are at higher risk for POAF. Thus, interventions targeting inflammation related to visceral obesity might help reducing the incidence of POAF.

Obesity and Metabolic Syndrome Are Independent Risk Factors for Atrial Fibrillation After Coronary Artery Bypass Graft Surgery

Postoperative atrial fibrillation (POAF) is a highly prevalent complication after cardiac surgery with substantial effects on outcomes. Previous studies have reported that obesity is a risk factor for POAF after cardiac surgery. However, it is unknown whether the metabolic syndrome (MS) also increases the risk of postoperative atrial fibrillation. We retrospectively analyzed the association between obesity and MS and the incidence of new-onset POAF in a total of 5085 patients who underwent isolated coronary artery bypass grafting surgery with no concomitant valvular surgery. Of these patients, 1468 (29%) were obese (body mass index > or = 30 kg/m2) and 2320 (46%) had a MS as defined by the NCEP-ATPIII. POAF occurred in 1374 (27%) of the patients. Obesity was associated (P<0.001) with increased incidence of POAF in the whole cohort as well as in patients > 50 years old but not in patients < or = 50 years old. In these patients, MS was the only metabolic factor to be significantly associated with higher incidence of POAF (12% versus 6%, P=0.01). In > 50-year-old patients, mild (30 < or = body mass index < 35 kg/m2) and moderate-severe (body mass index > or = 35 kg/m2) obesity were independently associated with a 1.4-fold (95% CI: 1.10 to 1.71; P=0.004) and 2.3-fold (95% CI: 1.71 to 3.13; P<0.0001) increase in the risk of POAF, respectively. In < or = 50-year-old patients, MS (relative risk [RR]: 2.36; 95% CI: 1.10 to 5.12; P=0.02) but not obesity was independently associated with POAF. This study demonstrates that obesity is a powerful risk factor for the occurrence of POAF after isolated coronary artery bypass grafting surgery in patients older than 50 years. However, in the younger population, this association is not observed and MS is the only metabolic risk factor to be independently associated with POAF.