Incidence Of Postoperative Atrial Fibrillation Research Articles

Scoring system for predicting the Post-Operative Atrial Fibrillation (POAF) in post-cardiac surgery: a literature review

Link of Video Abstract: https://youtu.be/tl9Q8g6DUdcBackground: Coronary artery bypass grafting (CABG) is still one of the optimal treatment options for revascularization in coronary heart disease. Despite Atrial Fibrillation being the most common arrhythmia after CABG, there’s still no agreement on which risk assessment to predict the incidence of Post Operative Atrial Fibrillation (POAF). Some studies have shown that the findings of Atrial fibrillation after CABG are associated with increased hemodynamic disturbances, thromboembolic manifestations, readmission to the Intensive Care Unit (ICU), increased length of stay, organ failure, and death. This study aims to analyze the scoring system used for predicting the incidence of POAF in cardiac surgery. Methods: This study used “POAF” AND “Scoring system," AND "CABG” AND “Atrial Fibrillation” as keywords to explore the literature from PubMed, Google Scholar, ProQuest, and Clinical Key. Search engines were searched for relevant papers from the last 15 years. Result: CHA2DS2-VASc score has a sensitivity of 74.2%, a specificity of 44.7% and can identify patients who are predicted to have a high risk of experiencing POAF by 49.4%. The CHA2DS2-VASc score can be used as an independent predictor for predicting POAF. HATCH score cut-off point exceeding 1 was linked to AF prediction, yielding a sensitivity of 42% and specificity of 70%. POAF Score, the scoring system anticipates an increased likelihood of POAF development (58.5%). A score of 1 corresponds to a 30.1% probability of POAF occurrence and is a practical point for commencing preventive therapy. Conclusion: Despite the various scoring systems used to predict postoperative atrial fibrillation, including the CHA2DS2-VASc score, HATCH score and Mariscalco. POAF Score demonstrated a validated ability to predict POAF.

Age-Related Association between Sex and Postoperative Atrial Fibrillation in Non-Cardiac Surgery Patients: Observational Cohort Study.

Postoperative atrial fibrillation (POAF) is a common complication that has shown conflicting results regarding sex differences. The potential effect of age on this association has not been adequately explored. We hypothesized that younger males would have a higher risk of POAF than females and that this difference would vary by age group. In this observational cohort study, we enrolled consecutive patients who underwent non-cardiac surgery between January 2011 and June 2019 at our institution and excluded those with preoperative atrial fibrillation and those undergoing sex-specific surgery. We stratified the patients into four groups based on their sex and age: females younger than 50 years, females older than 50 years, males younger than 50 years, and males older than 50 years. The primary outcome was the incidence of POAF. Of the 141,337 patients included in the study, 6414 (4.5%) were treated for POAF. The incidence of POAF was highest in males older than 50 years (7.4%), followed by females older than 50 years (4.6%), males younger than 50 years (2.1%), and females younger than 50 years (1.9%). After adjusting for potential confounding factors, the risk of POAF was significantly increased in all groups compared with females younger than 50 years, with an odds ratio (OR) of 2.43 (95% confidence interval [CI]: 2.17-2.73, p 0.001) for females older than 50 years, 1.19 (95% CI: 1.05-1.35, p = 0.01) for males younger than 50 years, and 4.39 (95% CI: 3.91-4.94, p 0.001) for males older than 50 years. The OR for POAF risk according to sex peaked between 60 and 70 years old and decreased gradually thereafter. Our study suggests that sex and age are important factors associated with the risk of POAF in non-cardiac surgery patients and that sex-specific and age-specific risk stratification and interventions might be needed to prevent and manage POAF in non-cardiac surgery patients. Further studies are needed to better understand the underlying mechanisms of sex and age differences in POAF and to develop more targeted and effective interventions to reduce the incidence of this common postoperative complication.

Perioperative systemic magnesium sulfate minimizes the incidence of atrial fibrillation after thoracotomy for lung resection: a prospective observational study.

Postoperative atrial fibrillation (POAF) is the most common complication following general thoracic surgery. POAF significantly increases the risk of adverse cardiovascular events, such as thromboembolism, heart failure, and mortality. Additionally, it also leads to prolonged hospital stays and higher costs. The objective of this observational study was to examine the impact of perioperative administration of magnesium sulphate (MgSO4) on the incidence of POAF. A prospective observational study was conducted, enrolling one hundred patients undergoing thoracotomy for lung resection. We compared the incidence of atrial fibrillation (AF) before and after implementing a change in our standard anesthetic management, which involved the addition of MgSO4. MgSO4 was administered during anesthesia induction at a dose of 40 mg/kg over ten minutes, followed by a 24-hour infusion at a rate of 10 mg/kg/h. The primary outcome was the incidence of POAF within the first seven days after surgery. Within the initial three days following surgery, there was no significant difference in the cumulative incidence of POAF between the MgSO4 group and the control group. However, on postoperative day 7, patients treated with MgSO4 exhibited a reduced incidence of POAF compared to the control group (4% vs. 26%; P=0.01). In the subgroup of patients not receiving pre-existing β-blockers, the addition of MgSO4 significantly decreased the occurrence of POAF (14% vs. 80%; P<0.001). Prophylactic administration of MgSO4 is a potentially beneficial approach for reducing the incidence of POAF after non-cardiac surgery, particularly in patients not receiving long-term β-blocker treatment.

Atrial fibrillation in vascular surgery: a systematic review and meta-analysis on prevalence, incidence and outcome implications.

To know the prevalence of atrial fibrillation (AF), as well as the incidence of postoperative AF (POAF) in vascular surgery for arterial diseases and its outcome implications. We performed a systematic review and meta-analysis following the PRISMA statement. After the selection process, we analyzed 44 records (30 for the prevalence of AF history and 14 for the incidence of POAF).The prevalence of history of AF was 11.5% [95% confidence interval (CI) 1-13.3] with high heterogeneity (I2 = 100%). Prevalence was higher in the case of endovascular procedures. History of AF was associated with a worse outcome in terms of in-hospital death [odds ratio (OR) 3.29; 95% CI 2.66-4.06; P < 0.0001; I2 94%] or stroke (OR 1.61; 95% CI 1.39-1.86; P < 0.0001; I2 91%).The pooled incidence of POAF was 3.6% (95% CI 2-6.4) with high heterogeneity (I2 = 100%). POAF risk was associated with older age (mean difference 4.67 years, 95% CI 2.38-6.96; P = 0.00007). The risk of POAF was lower in patients treated with endovascular procedures as compared with an open surgical procedure (OR 0.35; 95% CI 0.13-0.91; P = 0.03; I2 = 61%). In the setting of vascular surgery for arterial diseases a history of AF is found overall in 11.5% of patients, more frequently in the case of endovascular procedures, and is associated with worse outcomes in terms of short-term mortality and stroke.The incidence of POAF is overall 3.6%, and is lower in patients treated with an endovascular procedure as compared with open surgery procedures. The need for oral anticoagulants for preventing AF-related stroke should be evaluated with randomized clinical trials.

Comparison of the outcomes between total arch replacement and nontotal arch replacement in patients with acute type A aortic dissection

ObjectiveTo compare the outcomes between total arch replacement (TAR) and nontotal arch replacement (non-TAR) in patients with acute type A aortic dissection (ATAAD).MethodsBetween 2006 and 2018, 275 ATAAD patients were divided into 2 groups, the TAR group (n = 63) and the non-TAR group (n = 212), and multiple variables were analyzed.ResultsThe TAR patients were older than the non-TAR patients (61.5 ± 11.8 vs. 57.4 ± 14.5 years, p = 0.024). The TAR group had longer operative, cardiopulmonary bypass, aortic clamping, and circulatory arrest times than the non-TAR group (all p < 0.001). The overall hospital mortality rate was 8.7% with no statistically significant difference between the TAR and non-TAR groups (9.5% vs. 8.5%, p = 0.799). There was no significant difference in the incidence of acute kidney injury (AKI), intubation time, incidence of postoperative atrial fibrillation (AF), or reoperation for bleeding or reintervention rates between the TAR and non-TAR groups (68.3% vs. 65.7% (p = 0.912), 44.8% vs. 33.8% (p = 0.127), 30.2% vs. 22.6% (p = 0.222), 9.5% vs. 9.5% (p = 0.189), and 7.9% vs. 7.1% (p = 0.077), respectively). The TAR group had a higher rate of new permanent neurological deficit (PND) than the non-TAR group and longer median length of hospital stay (17.5% vs. 6.1% (p < 0.001) and 9 vs. 12 days (p = 0.049), respectively). TAR (relative risk (RR) 3.66, p = 0.005) and preoperative cardiopulmonary resuscitation (CPR) (RR 6.60, p = 0.019) were risk factors of PND. Survival rate was similar between the two groups.ConclusionThe mortality rates in ATAAD patients with TAR and non-TAR were similar. However, the incidence of new permanent postoperative neurological deficit was significantly higher, and the length of hospital stay was longer in patients with TAR. TAR in ATAAD should be avoided especially in patients who have experienced preoperative CPR to abate risk of PND.

Association of preoperative CA-125 levels with early POAF after heart valve surgery: a single-center, retrospective study

ObjectiveCancer antigen-125 (CA-125), a tumor marker, has received increasing attention in recent years for its role in the cardiovascular field. However, no study has reported the association of CA-125 with early postoperative atrial fibrillation (POAF) after heart valve surgery. Therefore, the aim of this study was to assess whether there is a correlation between CA-125 and early postoperative POAF after heart valve surgery.MethodsPatients who underwent valve surgery at Fujian Heart Medical Center from January 2020 to August 2022 were retrospectively analyzed and divided into postoperative atrial fibrillation group (POAF group) and postoperative non-atrial fibrillation group (NO-POAF), and the differences in clinical data between the two groups were compared, and the variables with statistical significance in the univariate analysis were included in the COX regression analysis, and finally the receivers’ operating characteristics (ROC) curves were drawn.ResultsFrom January 2020 to August 2022, a total of 1653 patients underwent valve surgery. A total of 344 patients were finally included, including 52 patients (15.1%) in the POAF group and 292 patients (84.9%) in the NO-POAF group. Univariate analysis showed higher CA-125 levels in patients in the POAF group than in those in the NO-POAF group [27.89 (13.64, 61.54), 14.48 (9.87, 24.08), P = 0.000]. Analysis of the incidence of POAF based on CA-125 quartiles showed an incidence of up to 29.2% in the highest quartile (> 27.88). Multivariate COX regression analysis showed that CA-125 [OR = 1.006, 95% CI (1.002, 1.010), P = 0.001] was an independent predictor of POAF. The final ROC curve plot showed that the area under the curve for CA-125 was 0.669, with an optimal cut-off value of 27.08 U/ml, and the difference in the area under the curve between the two groups was statistically significant (P = 0.000).ConclusionElevated preoperative CA-125 levels can affect the incidence of POAF and have a predictive value for the occurrence of POAF in the early stage after valve surgery. However, due to the small sample size and single-center retrospective study, further validation of this result is needed.

The Management of Postoperative Atrial Fibrillation (POAF): A Systematic Review.

Postoperative atrial fibrillation (POAF) refers to new-onset atrial fibrillation (AF) that develops after surgery and is associated with an increased risk of mortality and thromboembolic events. The optimal management and treatment methods for POAF complications are not yet fully established. This systematic reviewaimed to evaluate the various treatment and management approachescurrently available in terms of their suitability, efficacy, and side effects in handling POAF incidence post-surgery. Google Scholar and PubMed electronic databases were searched extensively for relevant articlesexamining the various management techniques currently used to manage POAF and published between 2018 and 2023. Data were collected on the type of surgery the patients underwent, POAF definition period, intervention, and outcome of interest. Following a systematic assessment guided by the inclusion criteria, 10 of the 579 studies retrieved were included in this study, and 293,417 POAF cases were recorded. Three of these studies used different rhythm control and rate control treatments to manage POAF cases, while seven studies used various anticoagulation therapies to manage POAF incidence. For asymptomatic patients within one to three days of surgery, rate control is sufficient to manage POAF, and routine rhythm control is not needed; rhythm control should be reserved for patients who develop complications such as hemodynamic instability. Anticoagulation was performed in patients whose POAF exceededfour days after surgery. Anticoagulation was associated with an increased risk of mortality, stroke, thromboembolic events, and major bleeding in patients who underwent coronary artery bypass graft (CABG) surgery. In contrast, in a few other studies, anticoagulation treatment led to improved outcomes in patients who developed POAF. A wide range of management methods are available for POAF after different types of surgery. However, there is only limited evidence to guide the clinical practice. The data available are mainly retrospective and insufficient to accurately evaluate the efficacy of the various management methods available for POAF. Future research should make efforts to standardize the treatment for this condition.

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

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

Antiarrhythmic Potential of Epicardial Botulinum Toxin Injection for Suppression of Postoperative Atrial Fibrillation.

Following heart surgery, postoperative atrial fibrillation (AF) is the most prevalent kind of secondary AF and the most frequent adverse event. Postoperative AF is related to a number of unfavorable cardiac outcomes, such as heart failure, stroke, and death. However, the pharmacological treatment for postoperative AF is only relatively efficient and is frequently linked to detrimental complications, including symptomatic bradycardia with atrioventricular block due to rate control drugs and elevated hemorrhage hazard attributable to the administration of anticoagulants. Ablation procedures also result in the irreversible damage of cardiac anatomic structures, which may have long-term negative implications on heart performance. As a result, there is an unmet demand for treatments that can minimize the incidence of postoperative AF in an effective and safe manner. Botulinum toxin is an established neurotoxin that has progressively gained use in every medical science domain. It hinders the propagation of impulses across nerve fibers without causing immediate damage to the cardiac tissue. The transient feature of botulinum toxin action and the eventual restoration of the autonomic nervous system transmission are undeniably advantageous and may render botulinum toxin a potential and feasible treatment approach for postoperative AF.

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

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

Long-Term Effects of Postoperative Atrial Fibrillation following Mitral Valve Surgery.

New-onset postoperative atrial fibrillation (PoAF) is one of the most frequent yet serious complications following cardiac surgery. Long-term consequences have not been thoroughly investigated, and studies have included different cardiac operations. The objectives were to report the incidence and short- and long-term outcomes in patients with PoAF after mitral valve surgery. This is a retrospective cohort study of 1401 patients who underwent mitral valve surgery from 2009 to 2020. Patients were grouped according to the occurrence of PoAF (n = 236) and the nonoccurrence of PoAF (n = 1165). Long-term outcomes included mortality, heart failure rehospitalization, stroke, and mitral valve reinterventions. The overall incidence of PoAF was 16.8%. PoAF was associated with higher rates of operative mortality (8.9% vs. 3.3%, p < 0.001), stroke (6.9% vs. 1.5%, p < 0.001), and dialysis (13.6% vs. 3.5%, p < 0.001). ICU and hospital stays were significantly longer in patients with PoAF (p < 0.001 for both). PoAF was significantly associated with an increased risk of mortality [HR: 1.613 (95% CI: 1.048-2.483); p = 0.03], heart failure rehospitalization [HR: 2.156 (95% CI: 1.276-3.642); p = 0.004], and stroke [HR: 2.722 (95% CI: 1.321-5.607); p = 0.007]. However, PoAF was not associated with increased mitral valve reinterventions [HR: 0.938 (95% CI: 0.422-2.087); p = 0.875]. Atrial fibrillation after mitral valve surgery is a common complication, with an increased risk of operative mortality. PoAF was associated with lower long-term survival, increased heart failure rehospitalization, and stroke risk. Future studies are needed to evaluate strategies that can be implemented to improve the outcomes of these patients.

Development and validation of a diagnostic model based on left atrial diameter to predict postoperative atrial fibrillation after off-pump coronary artery bypass grafting.

This cohort study collected the clinical data of patients who underwent off-pump coronary artery bypass grafting (OPCABG) during hospitalization to observe the occurrence of postoperative atrial fibrillation (POAF), construct a POAF prediction model for CABG patients based on the left atrial diameter (LAD), and assist clinicians in making better medical decisions. In this study, all patients who had no prior history of arrhythmia and who had received isolated OPCABG between May 1, 2021, and February 1, 2022, at Beijing Anzhen Hospital Affiliated to Capital Medical University (n=749) were reviewed. Depending on an optimal cutoff obtained from receiver operating characteristic (ROC) curve analysis, patients were separated into two groups: a group with POAF (n=188) and a group without POAF (n=561). The incidence of POAF was then compared. Prediction models were built, and nomograms were plotted was plotted. Model evaluation, including calibration curve and decision curve analysis, was performed. In all, 188 out of 749 (25.1%) patients who underwent cardiac surgery experienced POAF. Multifactorial logistic regression analysis showed that age ≥66 years, LAD ≥39 mm, and post-OPCABG atrial fibrillation (AF) were independently associated. The prognostic nomogram model showed good concordance index (C-index) scores. Decision curve analysis suggested the clinical benefit of the prediction models. In this study, a prediction model for patients with POAF after OPCABG was assessed, which was shown to make more accurate predictions compared with the original risk prediction system. It may assist doctors to optimize management of patients with POAF.

Age-related Increase in Incidence of Postoperative Atrial Fibrillation Following Coronary Artery Bypass Grafting (CABG) Surgery

Atrial Fibrillation (AF) is one of the common arrhythmias after coronary artery bypass grafting (CABG) mostly occurs within 2 to 4 days. The advanced age is one of the important risk factors. Objective: To determine the frequency of Postoperative Atrial Fibrillation (POAF) in patients age between 30-65 years who underwent elective CABG Surgery. Methods: One hundred and thirty-seven Adult patients of either sex between age of 30 to 65 years with three vessel coronary artery disease underwent elective CABG surgery were included in our study. It was descriptive cross-sectional study, conducted at Tabba Heart Institute, Karachi, from December 2021 to June 2022. Postoperatively daily EKG was performed for the evidence of POAF. Results: One hundred and thirty-seven patients, between age group of 30-65 years among them 115 (84%) were male &amp; 22 (16%) were females with mean age of patients 55.91years were included in our study. Post-Operative Atrial Fibrillation (POAF) was observed in 12.4%, out of whom 76.5% were male while 23.5% were female. The mean day of onset of POAF was 2.38 days. The relationship between increasing age groups and AF was found to be statistically significant i.e. p-value 0.04. There is significant difference between age groups and maximum incidence of POAF were found in above 60 years. Conclusions: In our study frequency of POAF was found in 12.4 %with mean age of participants was found to be 55.91 ± 6.5 years. Objective: To determine the frequency of Postoperative Atrial Fibrillation (POAF) in patients age between 30-65 years who underwent elective CABG Surgery. Methodology: One hundred and thirty seven Adult patients of either sex between age of 30 to 65 years with three vessel coronary artery disease underwent elective CABG surgery were included in our study. It was descriptive cross-sectional study, conducted at Tabba Heart Institute, Karachi, from December 2021 to June 2022. Postoperatively daily EKG was performed for the evidence of POAF. RESULT: One hundred and thirty seven patients, between age group of 30-65 years among them 115 (84%) were male &amp; 22 (16%) were females with mean age of patients 55.91years were included in our study. Post-Operative Atrial Fibrillation (POAF) was observed in 12.4%, out of whom 76.5% were male while 23.5% were female. The mean day of onset of POAF was 2.38 days. The relationship between increasing age groups and AF was found to be statistically significant i.e. p-value 0.04. There is significant difference between age groups and maximum incidence of POAF were found in above 60 years. CONCLUSION: In our study frequency of POAF was found in 12.4 %with mean age of participants was found to be 55.91 + 6.5 years.

Validation of a new species for studying postoperative atrial fibrillation: Swine sterile pericarditis model.

The canine sterile pericarditis model associated with atrial inflammation is an experimental counterpart of postoperative atrial fibrillation (POAF). However, the use of canines for research is restricted by ethics committees in many countries, and social acceptance is declining. To validate the feasibility of the swine sterile pericarditis model as an experimental counterpart to study POAF. Seven domestic pigs (35-60kg) underwent initial pericarditis surgery. On two or more postoperative days in the closed-chest state, we performed electrophysiological measurements of pacing threshold and atrial effective refractory period (AERP) while pacing from the right atrial appendage (RAA) and the posterior left atrium (PLA). The inducibility of POAF(>5min) by burst pacing was determined in both the conscious and anesthetized closed-chest state. These data were compared to previously published canine sterile pericarditis data for validation. The pacing threshold increased from day 1 to day 3 (2±0.1 to 3.3±0.6mA in the RAA, 2.5±0.1 to 4.8±0.2mA in the PLA). Also, the AERP increased from day 1 to day 3 (118±8 to 157±16ms in the RAA; 98±4 to 124±2ms in the PLA, both p<.05). Induction of sustained POAF occurred in 43% (POAF CL range 74-124ms). All electrophysiologic data from the swine model were consistent with the canine model with respect to (1) the range of both pacing threshold and AERP; (2) the progressive increase in threshold and AERP over time; (3) a 40%-50% incidence of POAF. A newly developed swine sterile pericarditis model demonstrated electrophysiologic properties consistent with the canine model and patients after open heart surgery.

Impact of pulmonary vein anatomy and left atrial size on postoperative atrial fibrillation after esophagectomy for esophageal cancer.

This study aimed to investigate the relationship between postoperative atrial fibrillation (POAF) after esophagectomy and pre-existing cardiac substrate. We retrospectively analyzed 212 consecutive patients from between July 2010 and December 2022 who were scheduled to undergo esophagectomy for esophageal cancer without previous history of atrial fibrillation. All the patients underwent both echocardiography and contrast-enhanced multi-detector computed tomography (MDCT). POAF occurred in 49 patients (23.1%). Multivariable logistic analysis demonstrated that independent predictors for POAF were age [OR; 1.06 (1.01-1.10), P < 0.01), three-field lymph node dissection [OR; 2.55 (1.25-5.23), P < 0.01), left atrial dilatation (> 35mm) assessment by echocardiography [OR; 3.05 (1.49-6.25), P < 0.01) and common left pulmonary vein [OR; 3.03 (1.44-6.39), P < 0.01). The correlation coefficient was high for left atrial dimensions assessed by echocardiography and MDCT (r = 0.91, P < 0.01). Combination of left atrial dilatation by echocardiography and common left pulmonary vein had high odds ratio [OR; 8.10 (2.62-25.96), P < 0.01). Instead of echocardiographic assessment, combination of left atrial enlargement (> 35mm) assessed by MDCT and common left pulmonary vein also showed high odds ratio for POAF [OR; 11.23 [2.19-57.63], P < 0.01). Incidence of POAF after esophagectomy was related to both left atrial enlargement and common left pulmonary vein assessed by preoperative MDCT. Additional analysis of atrial size and pulmonary vein variation would facilitate preoperative assessment of the risk of POAF, but future studies must ascertain therapeutic strategy.

Preemptive Pharmacogenetic-Guided Metoprolol Management for Postoperative Atrial Fibrillation in Cardiac Surgery: The Preemptive Pharmacogenetic-Guided Metoprolol Management for Atrial Fibrillation in Cardiac Surgery Pilot Trial

To test the hypothesis that implementation of a cytochrome P-450 2D6 (CYP2D6) genotype-guided perioperative metoprolol administration will reduce the risk of postoperative atrial fibrillation (AF), the authors conducted the Preemptive Pharmacogenetic-Guided Metoprolol Management for Atrial Fibrillation in Cardiac Surgery pilot study. Clinical pilot trial. Single academic center. Seventy-three cardiac surgery patients. Patients were classified as normal, intermediate, poor, or ultrarapid metabolizers after testing for their CYP2D6 genotype. A clinical decision support tool in the electronic health record advised providers on CYP2D6 genotype-guided metoprolol dosing. Using historical data, the Bayesian method was used to compare the incidence of postoperative AF in patients with altered metabolizer status to the reference incidence. A logistic regression analysis was performed to study the association between the metabolizer status and postoperative AF while controlling for the Multicenter Study of Perioperative Ischemia AF Risk Index. Of the 73 patients, 30% (n=22) developed postoperative AF; 89% (n=65) were normal metabolizers; 11% (n=8) were poor/intermediate metabolizers; and there were no ultrarapid metabolizer patients identified. The estimated rate of postoperative AF in patients with altered metabolizer status was 30% (95% CI 8%-60%), compared with the historical reference incidence (27%). In the risk-adjusted analysis, there was insufficient evidence to conclude that modifying metoprolol dosing based on poor/intermediate metabolizer status was associated significantly with the odds of postoperative AF (odds ratio 0.82, 95% CI 0.15-4.55, p=0.82). A CYP2D6 genotype-guided metoprolol management was not associated with a reduction of postoperative AF after cardiac surgery.

Acupuncture after valve surgery is feasible and shows promise in reducing postoperative atrial fibrillation: The ACU-Heart pilot trial

ObjectiveAcupuncture is an effective treatment for arrythmias and postoperative symptoms but has not been investigated after cardiac surgery. Acupuncture After Heart Surgery is a prospective, randomized, controlled pilot trial of daily inpatient acupuncture or standard care after valve surgery with the primary end point being feasibility and secondary end points being reduction in postoperative atrial fibrillation incidence and postoperative symptoms. MethodsA total of 100 patients without a history of atrial fibrillation underwent primary valve surgery via sternotomy and randomized 1:1 to acupuncture (51) or standard care (49). The acupuncture group received daily inpatient sessions starting on postoperative day 1. Postoperative symptoms (pain, nausea, stress, anxiety) were assessed once daily in the standard care group and before/after daily intervention in the acupuncture group. The groups were comparable except for age (acupuncture: 55.6 ± 11.4 years, standard care: 61.0 ± 9.3 years; P = .01). ResultsThe Acupuncture After Heart Surgery pilot trial met primary and secondary end points. There were no adverse events. An average of 3.8 (±1.1) acupuncture sessions were delivered per patient during a mean hospital stay of 4.6 days (±1.3). Acupuncture was associated with a reduction in pain, nausea, stress, and anxiety after each session (P < .0001), and patients receiving acupuncture had reduced postoperative stress and anxiety across admission compared with standard care (P = .049 and P = .036, respectively). Acupuncture was associated with reduced postoperative atrial fibrillation incidence (acupuncture: 7 [13.7%], standard care: 16 [32.7%]; P = .028), fewer discharges on amiodarone (acupuncture: 5 [9.8%], standard care: 13 [26.5%]; P = .03), and fewer hours in the intensive care unit (acupuncture: 30.3 ± 10.0, standard care: 37.0 ± 22.5; P = .057). ConclusionsAcupuncture after valve surgery is feasible, is well tolerated, and has clinical benefit. The reduction noted in postoperative atrial fibrillation incidence will inform larger trials designed to further investigate the impact of acupuncture on postoperative atrial fibrillation and medical outcomes.

Preclinical safety and biodistribution assessment of Ad-KCNH2-G628S administered via atrial painting in New Zealand white rabbits.

Post-operative atrial fibrillation (POAF) is the most common complication after cardiac surgery. Despite implementation of several pharmacological strategies, incidence of POAF remains at approximately 30%. An adenovirus vector encoding KCNH2-G628S has proven efficacious in a porcine model of AF. In this preclinical study, 1.5 × 1010 or 1.5 × 1012 Ad-KCNH2-G628S vector particles (vp) were applied to the atrial epicardium or 1.5 × 1012 vp were applied to the whole epicardial surface of New Zealand White rabbits. Saline and vector vehicle served as procedure controls. Animals were followed for up to 42 days. Vector genomes persisted in the atria up to 42 days, with no distribution to extra-thoracic organs. There were no adverse effects attributable to test article on standard toxicological endpoints or on blood pressure, left atrial or ventricular ejection fractions, electrocardiographic parameters, or serum IL-6 or troponin concentrations. Mononuclear infiltration of the myocardium of the atrial free walls of low-dose, but not high-dose animals was observed at 7 and 21 days, but these changes did not persist or affect cardiac function. After scaling for heart size, results indicate the test article is safe at doses up to 25 times the maximum proposed for the human clinical trial.

LB-456091-1 UNEXPECTED INCREASE IN POSTOPERATIVE ATRIAL FIBRILLATION BY CALCIUM-MEDIATED AUTONOMIC DENERVATION: THE CAP-AF2 RANDOMIZED CLINICAL TRIAL

In the CAP-AF trial, injection of calcium chloride (CaCl2) into the four major atrial ganglionated plexi (GP) reduced the incidence of postoperative atrial fibrillation (POAF) by 63% in patients undergoing coronary artery bypass (CABG). The CAP-AF2 trial intended to investigate if similar autonomic denervation could prevent POAF in patients with mitral regurgitation (MR) but without persistent AF who underwent surgery for MR.

High-Burden Premature Atrial Contractions Predict New-Onset Atrial Fibrillation After Surgical Septal Myectomy

Although increased premature atrial contractions (PACs) reportedly predict atrial fibrillation (AF) in both general and specific (e.g., patients with stroke) populations, early postoperative AF (POAF) risk in patients with increased PAC burden who require cardiac surgery remains unclear. We examined the correlation between different preoperative PAC burdens and POAF in patients with obstructive hypertrophic cardiomyopathy (OHCM) who underwent surgical treatment. We analyzed 304 consecutively admitted patients with OHCM without previous AF who underwent isolated septal myectomy between January 2015 and December 2018. All patients underwent preoperative 24-hour Holter electrocardiogram monitoring. PACs were present in 259 patients (85.20%) and absent in 45 patients (14.80%). According to the cut-off PAC number of 100beats/24hours, there were 211 patients (69.41%) with low-burden PACs and 48 patients (15.79%) with high-burden PACs. AF after septal myectomy occurred in 73 patients, which consisted of 3/45 in the non-PAC group (6.67%), 47/211 in the low-PAC-burden group (22.27%), and 23/48 in the high PAC burden group (47.92%). POAF incidence was higher in both low- and high-burden patients than in patients without PAC (p <0.01). Multivariate logistic regression analyses demonstrated that high-burden PACs (p=0.02) and age (p <0.01) but not low-burden PACs (p=0.22) independently predicted POAF in patients with OHCM. The area under the receiver operating characteristic curve for preoperative PACs was 0.72 (95% confidence interval 0.66 to 0.79, p <0.01, sensitivity: 68.49%, specificity: 69.26%). In conclusion, POAF incidence was significantly higher in patients with preoperative high-burden PACs and can predict POAF in patients with OHCM.