Incidence Of Postoperative Atrial Fibrillation Research Articles

The effect of spironolactone in reducing the risk of postoperative atrial fibrillation in patients undergoing coronary artery bypass graft surgery: randomized single-blind placebo-controlled study.

Postoperative atrial fibrillation (POAF), one of the most common cardiac arrhythmias following coronary artery bypass graft (CABG) surgery is associated with unfavorable outcomes. This study investigated the effect of spironolactone administered two weeks before surgery on the incidence of POAF in patients undergoing CABG. This randomized single-blind placebo-controlled study was conducted on 130 CABG patients. All patients were randomly divided into intervention and control groups including 65 cases for each group. In the intervention group, patients received 50 mg of spironolactone orally daily for 2 weeks before surgery, and in the control group patients received placebo daily from 2 weeks before surgery. All patients were continuously monitored for the occurrence of POAF for two weeks postoperatively. The mean age of the patients in the intervention and control groups was 61.7 ± 5.4 and 60 ± 6.7 years, respectively. The incidence of POAF in the intervention and control groups was 7.7% and 20%, respectively (Odds Ratio = 0.33, P = 0.042). All demographic and clinical variables were similar in patients with and without POAF (all P > 0.05). Our findings revealed that in comparison to placebo, the use of spironolactone is associated with reduced incidence of POAF in CABG candidates.

Colchicine in patients with coronary disease undergoing coronary artery bypass surgery: a meta-analysis of randomized controlled trials

Abstract Background Recent randomized evidence has shown that low dose colchicine lowers the risk of cardiovascular events in patients with chronic coronary artery disease (CAD). Colchicine has also been used in coronary artery bypass grafting (CABG) with individual studies suggesting protective effects for postoperative atrial fibrillation (POAF). We performed a meta-analysis of studies assessing the effect of colchicine on outcomes in CABG surgery. Purpose To determine the potential of colchicine for reducing post-operative atrial fibrillation or other adverse events in patients undergoing CABG. Methods We systematically searched three libraries (MEDLINE, Web of Science and The Cochrane Library) selecting all randomized control trials (RCT) including patients who underwent CABG and were randomized for pre- or perioperative administration of colchicine versus standard of care. Primary outcome was incidence of POAF. Inverse variance method (DerSimonian&Laird) and random effects model were performed. The leave-one-out analysis was carried out as a sensitivity analysis to address possible outliers. Results From 205 screened studies, five met the inclusion criteria and were selected. The data from 839 patients were included in the final analysis. Included studies were published between 2014 and 2022. The perioperative administration of colchicine was associated with reduction of POAF rates after CABG when compared to standard of care (relative risk; RR= 0.54, 95% confidence interval; CI, 0.40-0.73, p<0.01 – Fig. 1). The leave-one-out analysis confirmed the robustness of the analysis, with minimal variations of the confidence interval (Fig. 2). Conclusions This meta-analysis of randomized studies suggests that the perioperative administration of colchicine is associated with significant reduction of POAF rates after CABG.Forest plotLeave-one-out analysis

Safety of left atrial appendage amputation during cardiothoracic surgery

Abstract Background Patients with atrial fibrillation (AF) are at risk for ischemic strokes, often originating from the left atrial appendage (LAA). Preventive LAA amputation (LAAA) during cardiac surgery has been shown to reduce ischemic stroke risk, both in patients with and without AF. However, the short-term safety and functional implication of LAAA in non-AF patients remain poorly understood. Besides possible surgical complications, there are suggestions that LAAA could lead to postoperative AF or influence neurohumoral changes resulting in fluid overload. Purpose To evaluate the safety of LAAA in patients without a history of AF undergoing routine cardiac surgery. Methods Patients underwent elective cardiac surgery between May 5 2015 and April 18 2018 in two high volume centers. Main inclusion criteria were a CHA2DS2-VASc≥ 2 and no history of AF. Patients without a history of AF, that participated in the PREDICT-AF study underwent concomitant LAAA and were compared with patients undergoing cardiothoracic surgery who were approached for participation in PREDICT-AF, but declined and subsequently did not undergo LAAA. Informed consent for the retrospective use of data was obtained through an opt-out procedure in these patients. The primary outcome of this analysis was the number of patients with any serious adverse event within 30 days postoperatively. Secondary outcomes were AF within 30 days postoperatively, death, rethoracotomy, time on extra corporal circulation(ECC) and heart failure related symptoms assessed through congestion on x-chest and weight trends. Adverse events were independently adjudicated by a cardiothoracic surgeon using pre-specified definitions. Results 150 patients in PREDICT-AF underwent LAAA. 284 Eligible patients declined participation and formed the control group. Patients in the LAAA group were more frequently male (87.3% vs 72.5%; p=0.001), were taller (176.0cm ± 8.2 vs 172.6cm ± 9.9; p<0.001) and weighed more (86.1kg CI[80.0, 92.2] vs 81.6kg CI[71.9, 91.1]; p=0.001) compared to controls. There were no significant differences in occurrences of serious adverse events (8% vs 12%; p=0.265), deaths (1.3% vs 1.8%; p=1) or rethoracotomies (3.3% vs 1.8%; p=0.483) between the LAAA and control group. Also, there was no difference in the incidence of postoperative AF (57, 38% vs 90, 31.7%; p=0.225), ECC time (104.5 minutes CI[81.0, 129.0] vs 98.0 CI[80.0, 124.5] p=0.371) or the presence of chest x-ray congestion (26.0% vs 27.8%; p=0.771) between the groups (Figure 1A). The spline plot of perioperative weight change from baseline, reveals no notable differences between the two groups (Figure 1B). Conclusion LAAA during routine cardiothoracic surgery is not associated with more surgical complications, postoperative atrial fibrillation or heart failure related symptoms. Given the generally high AF risk in patients undergoing cardiothoracic surgery, a strategy to preemptively resect the LAA may be feasible and safe.Figure 1 A & B

Calcitonin signalling system regulates function and arhythmogenicity of atrial cardiomyocytes

Abstract Background Atrial fibrillation (AF) poses a significant therapeutic challenge due to myocardial remodelling, involving both structural and electrical alterations. Recent investigations have shed light on the role of atrial cardiomyocytes (CMs) in secreting Calcitonin (CT), a factor crucial for maintaining atrial tissue integrity. Dysregulated CT secretion in AF showed to contribute to fibrotic tissue production by atrial fibroblasts, exacerbating arrhythmogenesis [1]. However, the direct impact of CT on CM function and arrhythmogenicity remains unclear, driving the objectives of our study. Methods/Results Serum samples from 20 cardiac surgery patients revealed a noteworthy association between higher pre-operative CT levels and a significant ~2.8-fold reduction in the incidence of post-operative AF (poAF). Using freshly isolated atrial guinea pig CMs, confirmed (by qPCR and immunofluorescence) that CMs express CT-receptor (CTR) to enable CT actions in the cell. Functional studies found that CT administration inhibits spontaneous calcium (Ca2+)-release events induced by pacing and decreases the Ca2+ transients amplitude (at 2 Hz; IonOptix μstep system) in fura2-loaded CMs (n=22 cells) in a concentration-dependent manner. Atrial iPSC-CMs transduced with global RGECO sensor (Genetically encoded Ca2+ indicator) and treated with 15 pM CT showed a reduction in the beat rate when paced at 2Hz, and a significantly increased the time to 50% baseline. Evaluation of the expression and phosphorylation of selected Ca2+ handling proteins, which may potentially account for the observed changes in Ca2+ transients, showed no differences in total or phospho-(ser2808) ryanodine receptor, and SERCA2α in response to CT but an increase in phospho-(Ser16) Phospholamban. Conclusion Our findings highlight the effects of CT on atrial CM function. Maintaining physiological CT levels offer a promising approach for managing AF clinically, potentially through the use of already in clinical use CT-analogues.

Novel role of human epicardial adipocyte-derived SPARCL1 in suppression of postoperative atrial fibrillation in patients undergoing cardiovascular surgery

Abstract Background Postoperative atrial fibrillation (POAF) occurs in 20-50% after cardiovascular surgery and is associated with the short and long-term morbidity/mortality. The epicardial adipose tissue (EAT) may have a potential role to regulate the incidence of POAF. Purpose We explored the possible role of human epicardial adipocyte-derived adipokines in the regulation of the myocardial redox state and POAF. Methods We prospectively evaluated 149 patients without known AF who underwent scheduled open-heart cardiovascular surgery between May 2020 and November 2022. They were divided into POAF or Non-POAF group and followed up after discharge (476.6 ± 290.0 days). POAF was defined as AF lasting more than 30 seconds after the surgery. Human EAT samples were obtained from these patients during surgery and the preadipocytes were isolated. Preadipocytes were terminally differentiated to mature adipocytes and mRNAs were extracted. Genome-wide expression profiling of 6 vs. 6 matched samples of the POAF and Non-POAF groups was performed using Microarray analysis, and the results were validated with qPCR in all the cohort samples. The effects of secreted adipokines on the cardiomyocytes were assessed in terms of oxidative stress. Superoxide and whole reactive oxygen species (ROS) were evaluated with luminometry and live-cell fluorescent probes respectively. As the oxidative stress associated signalling, the phosphorylation of ERK and p38-MAPK were evaluated with western blotting. Angiotensin II (Ang-II) was used to induce oxidative stress and phosphorylation of MAPK. Results POAF was observed in 53 patients (36%). Microarray analysis (n = 6) revealed that there were 132 down- or up-regulated cording genes in epicardial adipocytes of the POAF group compared to the Non-POAF group. Of these genes, 11 genes cording secretable molecules were validated by qPCR (n = 69), showing that only SPARCL1 had significantly downregulated in the POAF group compared to the Non-POAF group (P = 0.005). Superoxide and ROS were induced by Ang II (P < 0.01) and attenuated by SPARCL1 dose-dependent manner (P < 0.01) in neonatal rat cardiomyocytes. The phosphorylation of ERK and p38-MAPK were induced by Ang II (P < 0.01) and attenuated by SPARCL1 (P < 0.01) dose-dependently. Co-culture of human induced pluripotent stem cell-derived atrial cardiomyocytes (iPS-ACM) and human epicardial adipocytes revealed that the adipocytes derived from Non-POAF group suppressed the superoxide (P = 0.002) and ROS (P = 0.02) in iPS-ACM compared to POAF group. Kaplan-Meier survival analysis revealed that the POAF group (P = 0.01) and low SPARCL1 expression in epicardial adipocytes (P = 0.018) were associated with a higher incidence of long-term adverse cardiovascular events after surgery. Conclusion: SPARCL1 derived from epicardial adipocytes may play an important role in the suppression of POAF and long-term cardiovascular events via improving the myocardial redox state.

Right anterior thoracotomy vs. upper hemisternotomy for aortic valve replacement with Perceval S: is there a difference?

Our study aimed to evaluate the early outcomes of aortic valve replacement with Perceval S sutureless valve through the right anterior thoracotomy and upper hemisternotomy approaches, and to determine if there are any differences between these two approaches. We carried out a study using data from 174 patients who underwent minimally invasive Perceval S valve implantation for aortic valve stenosis between January 2018 and August 2023. This was a retrospective, single-center observational study. The patients were divided into two groups: the hemisternotomy group (n = 100) and the right anterior thoracotomy group (n = 74). The overall in-hospital mortality was 1,7%. The cardiopulmonary bypass and cross-clamp times were longer in the right anterior thoracotomy group (p < .001). There were no statistically significant differences in terms of stroke, paravalvular leak, mechanical ventilation time, blood transfusion requirements, pacemaker implantation, reexploration for bleeding, conversion, wound infection, or in-hospital stay. Postoperative chest drainage was lower (p < .001) and postoperative atrial fibrillation occurred less frequently (p = .044) in the right anterior thoracotomy group. The median intensive care unit stay was shorter in the right anterior thoracotomy group (p = .018). Aortic valve replacement with the Perceval S valve through either an upper hemisternotomy or a right anterior thoracotomy is a procedure associated with low perioperative complication rates. Right anterior thoracotomy for an aortic valve replacement with the Perceval S valve was associated with lower postoperative bleeding, a lower postoperative atrial fibrillation incidence and a shorter intensive care unit stay compared to upper hemistornotomy.

L-Carnitine: A New Therapeutic Option for the Prevention of Atrial Fibrillation in Non-Cardiac Surgery-A Single-Group Interventional Pilot Study.

Background: L-carnitine is essential in lipid metabolism and reportedly has preventive effects for arrhythmia. Our objective was to examine the incidence of postoperative atrial fibrillation (POAF) and changes in serum biomarker levels following perioperative L-carnitine administration in patients with lung cancer. Methods: Thirteen patients undergoing a lobectomy with preoperative serum brain natriuretic peptide levels >24 pg/mL were perioperatively administered L-carnitine for 5 days (3 g/3×). Accurate 95% confidence intervals (CI) for POAF incidence were calculated. Serum biomarkers for POAF in lung cancer and target proteins for L-carnitine were evaluated by using open-source data from proteomic analysis. Results: The incidence of POAF was 38.5% (95% CI 13.9%-68.4%). Fatty acid-binding protein 4 (FABP4) was selected as a candidate biomarker from 1472, 63, and 26 proteins related to lung cancer, L-carnitine, and AF, respectively. A positive correlation was observed between the predicted POAF incidence rate and preoperative FABP4 levels (Pearson's r = 0.5183). The mean change in serum FABP4 after L-carnitine administration for 5 days was -2.9 ng/mL (95% CI -4.9 to -0.89 ng/mL). Conclusions: The incidence of POAF after a lobectomy was 38.5% after the perioperative administration of L-carnitine for patients at a high risk of POAF. The serum FABP4 level demonstrates potential as a candidate biomarker for POAF prediction.

Early postoperative outcomes of modified del Nido cardioplegia in coronary artery bypass surgery in patients with low ejection fraction

Background: This study aimed to investigate the intraoperative and early postoperative effects of modified del Nido cardioplegia (DNC) compared to classic blood cardioplegia (BC) in patients with impaired left ventricular ejection fraction (EF) who underwent isolated coronary artery bypass grafting (CABG). Methods: A total of 123 patients (108 males, 15 females; mean age: 62.2±8.5 years; range, 42 to 78 years) with an EF of 35% or lower who underwent on-pump CABG were included in the retrospective study between December 2022 and December 2023. The patients were divided into two groups according to the type of cardioplegia used: Group 1 (n=74) was designated as the BC group, and Group 2 (n=49) was designated as the DNC group. The groups were compared in terms of aortic cross-clamp duration, cardiopulmonary bypass (CPB) duration, need for defibrillation during weaning from CPB, positive inotrope requirement, intra-aortic balloon pump requirement, postoperative troponin-I levels, postoperative atrial fibrillation occurence, postoperative prolonged ventilation, development of postoperative neurologic complications, need for reintervention due to postoperative bleeding, postoperative transfusion requirement, and EF values at one month after the operation. Results: There was no significant difference between the two groups in the terms of aortic cross-clamp and CPB duration (p=0.955 vs. p=0.816). Additionally, there was no significant difference in the need for intra-aortic balloon pump usage between the two groups (p=0.105). Dopamine and dobutamine usage were significantly lower in Group 2 (p=0.04 and p=0.05, respectively). The intraoperative requirement for defibrillation was significantly lower in Group 2 (p=0.01). In addition, troponin levels at 12 h postoperatively were significantly lower in Group 2 (p=0.03). The incidence of postoperative atrial fibrillation was significantly lower in Group 2 (p=0.02). Moreover, there was no significant difference in EF values at one month after the operation (p=0.08). Conclusion: In patients who underwent CABG with reduced EF, modified DNC provided myocardial protection comparable to classic BC. Additionally, the need for intraoperative defibrillation and postoperative inotropic agents, as well as the incidence of postoperative atrial fibrillation, were lower in patients operated with DNC.

Impact of Multi versus Single Arterial Coronary Bypass Graft Surgery on Postoperative Atrial Fibrillation

The effect of multi-arterial (MA) versus single arterial (SA) coronary bypass graft surgery on postoperative atrial fibrillation (POAF) was not investigated. From May 2017 to May 2024, the patients with CYP2C19*2 or *3 allele receiving coronary artery grafting and post-operational aspirin 100 mg/day and clopidogrel 75mg/day were retrospectively reviewed and assigned into MA or SA group. The primary endpoint was the incidence rate of POAF in first week. The secondary endpoints were POAF burden, platelet aggregation, systemic immune-inflammation (SII) index and heart rate variability (HRV). The study included 58 cases in MA group and 174 cases in SA group. The incidence of POAF was 17% in MA group contrasting with 42% in SA group (hazard ratio: 0.353; 95% confidence interval: 0.218 to 0.569, P=0.0012). A lower POAF burden was observed in MA group than that in SA group (2 h [1, 5] versus 10 h [6, 20], P=0.02). Platelet aggregation (arachidonic acid, 46%±10% vs. 56%±8%, P<0.01; adenosine diphosphate, 58%±17% vs. 75%±13%, P<0.01) and inflammation response index (neutrophil-lymphocyte ratio, 26±4 vs. 28±5, P=0.006; SII index, 5019±771 vs. 5382±1204, P=0.032) was notably lower in MA group than those in SA group at one day after CABG. Holter electrocardiogram showed a higher HRV value in standard deviation of normal-to-normal RR intervals, and decreased low-frequency/high-frequency ratio in MA group. In conclusion, MA was associated with a lower incidence rate of POAF, and paralleled with a lower AF burden, platelet aggregation, inflammation reaction and a higher parasympathetic nerve tone compared with SA regimen.

Risk Factors of Postoperative Atrial Fibrillation After Isolated Coronary Artery Bypass Grafting Surgery in the Recent 10 Years: Clinical Analysis of 6229 Patients.

Postoperative atrial fibrillation (POAF) is a common complication after coronary artery bypass grafting (CABG) that prolongs hospitalization and increases expenses. Perioperative risk factors may predict POAF. From March 2015 to January 2023, 6229 patients who underwent isolated CABG and were in sinus rhythm before CABG were included in this retrospective study. The preoperative and postoperative variants of patients were collected and analyzed by univariate analyses between the patients with and without POAF. Multivariate logistic regression analysis was then used to study the independent risk factors for POAF. The incidence of POAF in this group of patients was 30.94%. Univariate analyses demonstrated that age (p < 0.001), hypertension (p < 0.001), smoking (p < 0.05), cardiopulmonary bypass (CPB) time (p < 0.01), and ejection fraction (EF, p < 0.01) were the risk factors for POAF. Multivariate logistic regression analysis determined the independent risk factors associated with POAF were old age (odds ratio [OR] = 1.062, p = 0.000) and low EF (OR = 0.980; p = 0.008). In the current era, after isolated CABG surgery, there is still a quite high incidence of POAF (30.94% in this group of CABG patients). The main risk factors correlating to POAF include age, hypertension, smoking, CPB time, and EF. Among these factors, multivariate analysis identified old age and low EF as the independent risk factors associated with POAF. Particular care should be taken in the perioperative period for these patients in the prevention of POAF.

Stroke Prevention With Prophylactic Left Atrial Appendage Occlusion in Cardiac Surgery Patients Without Atrial Fibrillation: A Meta-Analysis of Randomized and Propensity-Score Studies.

The role of left atrial appendage occlusion (LAAO) in patients without previous atrial fibrillation (AF) is not established. This meta-analysis was conducted on patients with normal sinus rhythm who underwent cardiac surgery, with and without concomitant LAAO, to evaluate its effect on the incidence of cerebrovascular accidents (CVAs). A systematic review was conducted from inception until December 2023 for randomized and propensity-score studies comparing CVA in patients without AF undergoing cardiac surgery with or without LAAO. Six studies met our inclusion criteria with a total of 4130 patients: 2146 in the LAAO group and 1984 in the no-LAAO group. The risk ratio of postoperative AF was 1.05 (95% CI, 0.86-1.28); P=0.628. The CVA rates at 5 years were 6.8±1.0% in the no-LAAO group and 4.3±0.8% in the LAAO group (log-rank P=0.021). The Cox regression analysis for CVA in patients undergoing LAAO reported a hazard ratio of 0.65 (95% CI, 0.45-0.94); P=0.022. Landmark analysis at 4 years highlighted a significant difference in overall survival between no-LAAO and LAAO groups, 86±12.2% versus 89.6±11.0%; P=0.041. In this meta-analysis of patients without previous AF undergoing cardiac surgery, LAAO was associated with a decreased risk of CVA, no difference in the incidence of postoperative atrial fibrillation, and a significant overall survival benefit at a 4-year landmark analysis. Although these findings support LAAO, the randomized LeAAPS trial (Left Atrial Appendage Exclusion for Prophylactic Stroke Reduction Trial), LAA-CLOSURE trial (A Randomized Prospective Multicenter Trial for Stroke Prevention by Prophylactic Surgical Closure of the Left Atrial Appendage in Patients Undergoing Bioprosthetic Aortic Valve Surgery), and LAACS-2 trial (Left Atrial Appendage Closure by Surgery-2) will help define the effectiveness of LAAO in patients undergoing cardiac surgery who have risk factors for AF and CVA. URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42024496366.

Central venus cannulation during cardiac surgery as a possible new additional risk factor for late post-operative atrial fibrillation insurgence.

Postoperative atrial fibrillation (POAF) is the most frequent cardiac arrhythmia following cardiac operations. It has been associated with an increased risk of postoperative cerebrovascular complications, morbidity and mortality. The aim of this study is to evaluate if the type of venous cannulation to institute the cardiopulmonary bypass (CPB) during major cardiac surgery procedures can influence the rate of POAF and late FA onset. We collected data from 2087 consecutive patients who have been operated at our Institution from January 2016 to December 2018. To obtain two homogenous groups we performed a propensity match analyzes: Group 1 for whom the blood drain of the CPB has been granted via peripheral cannulation (PC) through the right common femoral vein and Group 2 with patients who underwent central cannulation (CC) with insertion of a drainage cannula in the right atrium or in the superior and inferior vein cava. POAF has been observed as statistically similar between the two groups. At 1250-day follow-up, While the incidence of POAF was 2.9% and 8.7% in the PC and CC groups, respectively (p = .04). our data seems to show that the two groups do not differ in terms of POAF, while the CC group may have a significantly higher rate of atrial fibrillation in the follow-up period.

Colchicine in Patients With Coronary Disease Who Underwent Coronary Artery Bypass Surgery: A Meta-Analysis of Randomized Controlled Trials

Recent randomized evidence has shown that low-dose colchicine lowers the risk of cardiovascular events in patients with chronic coronary artery disease. Colchicine has also been used in coronary artery bypass grafting (CABG), with individual studies suggesting protective effects for postoperative atrial fibrillation (POAF). We performed a meta-analysis of studies assessing the effect of colchicine on outcomes in CABG surgery. We systematically searched 3 libraries (MEDLINE, Web of Science, and the Cochrane Library), selecting all randomized control trials including patients who underwent CABG and were randomized for perioperative administration of colchicine versus standard of care. The primary outcome was incidence of POAF. The inverse variance method (DerSimonian&Laird) and random-effects model were performed. The leave-one-out analysis was carried out as a sensitivity analysis to address possible outliers. From 205 screened studies, 5 met the inclusion criteria and were selected. The data from 839 patients were included in the final analysis. The included studies were published between 2014 and 2022. The perioperative administration of colchicine was associated with the reduction of POAF rates after CABG compared with standard of care (relative risk 0.54, 95% confidence interval 0.40 to 0.73, p <0.01). The leave-one-out analysis confirmed the robustness of the analysis, with minimal variations of the confidence interval. This meta-analysis of randomized studies suggests that the perioperative administration of colchicine is associated with significant reduction of POAF after CABG.

Effect of minimally invasive cardiac surgery on hospital length of stay: A systematic review and meta-analysis

Background: Perioperative management using minimally invasive cardiac surgery (MICS), compared to full sternotomy (FS) cardiac surgery, is considered to improve postoperative recovery, and reduce hospital length of stay (LOS). Methods: A comprehensive systematic search was conducted across MEDLINE/PubMed, Embase, and the Cochrane library to identify RCT comparing MICS to FS approach for aortic valve, mitral valve, and coronary artery bypass surgery. Meta-analysis of extracted data was performed using random effects models. Results: A total of 33 RCTs including 2920 patients were identified. Overall MD (95% CI) for hospital and intensive care unit (ICU) LOS after MICS was significantly shorter compared to FS (-0.88 days (-1.55;-0.20), p&lt;0.013; 2606 patients) and (-0.23 days (-0.41;-0.05), p=0.012; 2242 patients), respectively. Additionally, postoperative blood loss was reduced with the use of MICS, (-192.07 ml (-292.32;-91.82), p=0.002; 718 patients). There was no evidence for differences between both groups in terms of postoperative ventilation times, duration of surgery, reintervention rate, incidence of postoperative atrial fibrillation or stroke, hospital mortality, or 1-year mortality. Conclusion: Within the limitations of a meta-analysis, MICS was found to be effective in promoting faster recovery by reducing postoperative blood loss, ICU, and hospital LOS.

A posterior pericardial chest tube is associated with reduced incidence of postoperative atrial fibrillation after cardiac surgery: A propensity score–matched study

ObjectivePostoperative atrial fibrillation (POAF) is a common complication after cardiac surgery that is associated with other adverse outcomes. Recent studies have shown that drainage of pericardial effusion by a posterior pericardial incision reduces the incidence of POAF. An alternative approach is a chest tube placed posteriorly in the pericardium. We evaluated whether the use of a posterior pericardial drain was associated with reduced risk of POAF in patients undergoing coronary artery bypass graft (CABG) and/or aortic valve replacement (AVR). MethodsThis observational study included 2535 patients who underwent CABG (n = 1997), AVR (n = 293), or combined CABG and AVR (n = 245) in Iceland from 2002 to 2020. From our study population, 553 (22%) received a 20-Fr posterior pericardial chest tube in addition to standard mediastinal and left pleural drains. The incidence of POAF in patients with and without a posterior pericardial drain was compared before and after 1:1 propensity score matching. ResultsOf 2535 patients, 1100 were included in the matched cohort. The incidence of POAF was lower in patients receiving posterior pericardial chest tube drainage compared with the control group, both before (34% vs 43%, P < .001) and after (33% vs 43%, P = .002) matching. In a multivariable analysis, posterior pericardial chest tube drainage was independently associated with a reduced risk for POAF (adjusted odds ratio 0.67; 95% confidence interval, 0.52-0.88; P = .003). ConclusionsThis observational study suggested that posterior pericardial chest tube drainage is associated with a significant reduction of POAF after routine CABG and/or AVR procedures. The results are hypothesis-generating and must be confirmed in prospective randomized trials.

Sex, Atrial Fibrillation, and Long-Term Mortality After Cardiac Surgery

There are limited data on the association of sex with the incidence of postoperative atrial fibrillation (poAF) and subsequent long-term mortality after cardiac surgery. To evaluate whether the incidence of poAF and associated long-term mortality after cardiac surgery differ by sex. This retrospective cohort study was conducted at 2 tertiary care centers in Massachusetts from January 1, 2002, until October 1, 2016, with follow-up until December 1, 2022. Adult (aged >20 years) women and men undergoing coronary artery bypass graft surgery, aortic valve surgery, mitral valve surgery, and combined procedures with cardiopulmonary bypass were examined using medical records. Patients who had data on poAF were included in data analyses. Sex and poAF. Primary outcomes were the incidence of poAF and all-cause mortality. poAF was defined as any atrial fibrillation detected on electrocardiogram (EKG) during the index hospitalization in patients presenting for surgery in normal sinus rhythm. Data on poAF were obtained from EKG reports and supplemented by information from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. All-cause mortality was assessed via hospital records. The hypotheses were formulated prior to data analysis. Among 21 568 patients with poAF data (mean [SD] age, 66.5 [12.4] years), 2694 of 6601 women (40.8%) and 5805 of 14 967 men (38.8%) developed poAF. In a multivariable logistic regression model, women had lower risk of poAF (odds ratio [OR], 0.85; 95% CI, 0.79-0.91; P < .001). During the follow-up study period, 1294 women (50.4%) and 2376 men (48.9%) in the poAF group as well as 1273 women (49.6%) and 2484 men (51.1%) in the non-poAF group died. Cox proportional hazards analysis found that the association between poAF and mortality was significantly moderated (ie, effect modified) by sex. Compared with same-sex individuals without poAF, men with poAF had a 17% higher mortality hazard (hazard ratio [HR], 1.17; 95% CI, 1.11-1.25; P < .001), and women with poAF had a 31% higher mortality hazard (HR, 1.31; 95% CI, 1.21-1.42; P < .001). In this retrospective cohort study of 21 568 patients who underwent cardiac surgery, women were less likely to develop poAF than men when controlling for other relevant characteristics; however, women who did develop poAF had a higher risk of long-term mortality than men who developed poAF. This observed elevated risk calls for a tailored approach to perioperative care in women undergoing cardiac surgery.

Effect of Ticagrelor Versus Clopidogrel After Off-Pump Coronary Artery Bypass Grafting on Postoperative Atrial Fibrillation: A Cohort Study.

This study aimed to explore the effect of a P2Y12 inhibitor regimen on the occurrence of postoperative atrial fibrillation (POAF) after off-pump coronary artery bypass graft surgery in carriers with the cytochrome P450 family 2 subfamily C member19 loss-of-function allele. From May 2019 to November 2023, patients containing the cytochrome P450 family 2 subfamily C member19*2 or *3 allele undergoing elective first-time off-pump coronary artery bypass graft surgery including aspirin 100 mg/d and ticagrelor 180 mg/d (AT group; n=95) versus clopidogrel 75 mg/d (aspirin and clopidogrel group; n=95) were prospectively followed. The primary end point was the cumulative incidence of POAF in a week. The secondary end points were POAF burden, platelet aggregability, systemic immune-inflammation index and heart rate variability. The incidence of POAF was 21.1% in the AT group versus 41.1% in the aspirin and clopidogrel group (hazard ratio, 0.46 [95% CI, 0.27-0.76]; P=0.003). POAF burden, ADP-induced platelet aggregation and systemic immune-inflammation index was notably lower in the AT group than the aspirin and clopidogrel group. Heart rate variability data showed an increase in both high-frequency and SD of normal-to-normal RR intervals in the AT group with a decreased low-frequency/high-frequency ratio, suggesting that the sympathetic/parasympathetic activation was balanced. In patients carrying the cytochrome P450 family 2 subfamily C member19 loss-of-function allele, an AT regimen after off-pump coronary artery bypass grafting was associated with a lower incidence of POAF, paralleled by lower atrial fibrillation burden, ADP-induced platelet aggregation, lower systemic immune-inflammation index reaction, and a balanced automatic nerve system compared with an aspirin and clopidogrel regimen. Inhibiting the systemic immune-inflammation response and sustaining automatic nerve balance may underlie the therapeutic effect of POAF by a potent antiplatelet combination.

Fluid Balance and Risk of Postoperative Atrial Fibrillation after On-pump Coronary Artery Bypass Grafting Surgery

Background: Postoperative atrial fibrillation (POAF) is a common complication after coronary artery bypass grafting (CABG) and is associated with increased adverse outcomes. However, the relationship of fluid balance and POAF is not clear yet. Accordingly, this study aims to study the relationship of fluid balance and POAF, and to evaluate the other risk factors of POAF in patients undergoing elective on-pump CABG with or without valve surgery in our center. Methods: A retrospective study between October 2018 and December 2022 including 261 patients who underwent CABG undergoing cardiopulmonary bypass was performed. The fluid balance on the first 4 days in the intensive care unit (ICU) and other potential perioperative risk factors for POAF were collected and analyzed using univariate and multivariate analyses to identify risk factors following CABG. The in-hospital adverse outcomes of POAF were also evaluated. Results: 261 adult CABG patients were evaluated, of whom 22 were excluded due to a history of atrial fibrillation or other causes. Among them, 72 patients developed POAF (30.1%). The mean fluid balance was negative on the first 3 days. Negative fluid balance was less on postoperative day 0 (POD 0) in those developing POAF than in those not developing POAF (–12.88 ± 12.47 vs. –17.48 ± 10.03 mL/kg, p = 0.003). No differences were noted for POD 1 and POD 2. Multiple logistic regression analysis showed age &gt;60 years (adjusted odds ratio (OR), 3.86 [95% confidence interval (CI): 1.99 to 7.48]), left atrial antero-posterior (AP) dimension &gt;42 mm (adjusted OR, 2.68 [95% CI: 1.45 to 4.93]), total blood transfusions &gt;400 mL (adjusted OR, 1.96 [95% CI: 1.05 to 3.63]), and positive fluid balance on POD 0 (adjusted OR, 2.93 [95% CI: 1.01 to 8.51]) were independent perioperative risk factors for POAF. Conclusions: The incidence of POAF is not significantly reduced even with a fluid restriction strategy after CABG, and positive fluid balance on the day of surgery is a risk factor for POAF, rather than on POD 1 and POD 2. In addition, advanced age, left atrial enlargement, and increased perioperative blood transfusion are all risk factors for POAF.

Evaluation of the effect of empagliflozin on prevention of atrial fibrillation after coronary artery bypass grafting: a double-blind, randomized, placebo-controlled trial.

This study is aimed at evaluating the effect of empagliflozin in preventing atrial fibrillation after coronary artery bypass grafting (CABG). Eighty-two patients who fulfilled the inclusion criteria were allocated to the empagliflozin group (n = 43) or placebo group (n = 39). In two groups, patients received empagliflozin or placebo tablets 3days before surgery and on the first three postoperative days (for 6days) in addition to the standard regimen during hospitalization. During the first 3days after surgery, types of arrhythmias after cardiac surgery, including supraventricular arrhythmias, especially postoperative atrial fibrillation (POAF), ventricular arrhythmias, and heart blocks, were assessed by electrocardiogram monitoring. C-reactive protein (CRP) levels were evaluated pre-operatively and postoperative on the third day. The incidence of POAF in the treatment group was lower compared to the control group; however, this reduction was statistically non-significant (p = 0.09). The frequency of ventricular tachycardia was reduced significantly in the treatment group versus patients in the control (p = 0.02). Also, a significant reduction in the frequency of premature ventricular contractions (PVCs) was seen in the treatment group in comparison with the control group (p = 0.001). After the intervention, CRP levels were significantly less in the empagliflozin group compared to the control group in the third postoperative day (p = 0.04). The prophylactic use of empagliflozin effectively reduced the incidence of ventricular arrhythmia in patients undergoing CABG surgery.

New-Onset Postoperative Atrial Fibrillation and Preoperative Sleep in Cardiac Surgical Patients

BackgroundNew-onset postoperative atrial fibrillation is associated with adverse clinical outcomes in older adults. Poor preoperative sleep quality is a putative modifiable risk factor. The relationships between new-onset postoperative atrial fibrillation and preoperative sleep structure in older adults undergoing elective cardiac surgery were investigated at a single center. MethodsThis was a prespecified substudy within a prospective observational study of perioperative electroencephalographic markers (ClinicalTrials.gov; NCT03291626). We analyzed preoperative sleep recordings from 71 cardiac surgical patients aged ≥60 years without a prior history of atrial fibrillation. Overnight recordings were acquired using a consumer-grade headband and underwent manual sleep staging. Electroencephalographic slow wave activity (power in the 0.5-4 Hz frequency band) was computed in 1-minute intervals for non-rapid eye movement sleep stages. Associations between new-onset postoperative atrial fibrillation incidence and sleep measures were evaluated using univariate logistic regression models and multivariate logistic regression models including age and sex. ResultsNew-onset postoperative atrial fibrillation was present in 22 of 71 (31%) patients. A higher preoperative percentage of total sleep time in non-rapid eye movement stage 1 was associated with new-onset postoperative atrial fibrillation (median difference of 5.4%, P = .0002, Mann-Whitney U-test), independent of age and sex. No associations were observed between new-onset postoperative atrial fibrillation and other sleep metrics, including slow wave activity (all P > .05, Mann-Whitney U-test). ConclusionsExcess preoperative non-rapid eye movement stage 1 sleep, consistent with greater sleep fragmentation, is a potential modifiable target for mitigating new-onset postoperative atrial fibrillation risk in older adults undergoing elective cardiac surgery requiring cardiopulmonary bypass.