Risk Of Postoperative Atrial Fibrillation Research Articles

New-onset postoperative atrial fibrillation after pulmonary endarterectomy is associated with adverse outcomes.

New-onset postoperative atrial fibrillation (POAF) is a common complication after pulmonary thromboendarterectomy (PEA), yet the risk factors and their impact on prognosis remain poorly understood. This study aims to investigate the risk factors associated with new-onset POAF after PEA and elucidate its underlying connection with adverse postoperative outcomes. A retrospective analysis included 129 consecutive chronic thromboembolic pulmonary hypertension (CTEPH) patients and 16 sarcoma patients undergoing PEA. Univariate and multivariate analyses were conducted to examine the potential effects of preoperative and intraoperative variables on new-onset POAF following PEA. Propensity score matching (PSM) was then employed to adjust for confounding factors. Binary logistic regression revealed that age (odds ratio [OR] = 1.041, 95% confidence interval [CI] = 1.008-1.075, p = 0.014) and left atrial diameter[LAD] (OR = 1.105, 95% CI = 1.025-1.191, p = 0.009) were independent risk factors for new-onset POAF after PEA. The receiver operating characteristic (ROC) curve indicated that the predictive abilities of age and LAD for new-onset POAF were 0.652 and 0.684, respectively. Patients with new-onset POAF, compared with those without, exhibited a higher incidence of adverse outcomes (in-hospital mortality, acute heart failure, acute kidney insufficiency, reperfusion pulmonary edema). Propensity score matching (PSM) analyses confirmed the results. Advanced age and LAD independently contribute to the risk of new-onset POAF after PEA. Patients with new-onset POAF are more prone to adverse outcomes. Therefore, heightened vigilance and careful monitoring of POAF after PEA are warranted.

Association Between Obesity and Postoperative Atrial Fibrillation in Patients Undergoing Cardiac Surgery: An Updated Systematic Review

Postoperative atrial fibrillation (POAF) is a frequent and severe complication following cardiac surgery. While obesity is established as a risk factor for atrial fibrillation (AF) in non-surgical settings, its role in the postoperative period is still debated. This systematic review aims to assess the relationship between obesity and POAF in patients undergoing cardiac surgery. A comprehensive literature search was conducted in PubMed, Embase, Web of Science, and Cochrane Library, focusing on randomized controlled trials (RCTs) published until June 2023. Data were extracted independently by two authors and assessed using the Cochrane Risk of Bias Tool (RoB2). From an initial search of 1,284 articles, 11 studies met the inclusion criteria, with a range of sample sizes between 300 and 5,000 patients. The incidence of POAF in obese patients ranged from 30% to 54%, compared to 20% to 46% in non-obese patients. Five studies concluded that obesity was a significant risk factor for POAF, whereas four found no statistically significant relationship, and two reported an "obesity paradox," where obesity appeared protective or neutral regarding POAF risk. Our review provides evidence regarding obesity developing POAF after cardiac surgery.

Predicting 1-year non-cancer-related adverse events after lung resection.

Assessing the risk for non-cancer-related outcomes following lung cancer surgery is crucial for high-risk patients. This study examined non-cancer-related adverse events within 1 year after lung resection, emphasizing the role of resected lung volume and postoperative atrial fibrillation (POAF). We conducted a retrospective analysis of 460 patients who underwent anatomical lung resection for malignant lung tumours. We assessed perioperative factors, such as the number of resected subsegments and POAF, as potential predictors of 1-year non-cancer-related adverse events. Additionally, we validated a previously published nomogram for predicting POAF. One-year non-cancer-related adverse events occurred in 20% of patients. Multivariable analysis identified higher age, lower percentage-predicted forced expiratory volume in 1 second, greater number of resected subsegments and POAF as independent predictors of these adverse events. The incidence of POAF was 8.5%, with higher age, history of atrial fibrillation, and open thoracotomy as independent predictors. A temporal link between POAF and other severe postoperative complications was observed, as 71% of POAF cases preceded other complications. The nomogram's predicted risk for POAF was associated well with the actual incidence. Resected lung volume and POAF are statistically significant factors associated with non-cancer-related outcomes after lung resection. Minimizing resected lung volume when oncologically and technically feasible, along with identifying patients at risk for POAF, may contribute to improved postoperative outcomes. Our results have implications for risk stratification and preoperative decision-making in lung cancer surgery.

Abstract 16890: Postoperative Atrial Fibrillation Following Coronary Artery Bypass Surgery in Severe Obesity: Impact of Waist Circumference

Introduction: Obesity (body mass index (BMI) ≥ 30 kg/m 2 ) is an independent risk factor for postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) surgery. The incidence of POAF in patients with severe obesity (BMI ≥ 35 kg/m 2 ) is less studied. For a given BMI, higher waist circumference (WC) predicts adverse cardiovascular outcomes. Whether WC predicts POAF independently of BMI among patients with severe obesity remains unknown. Aim: To evaluate the risk of POAF after isolated CABG in patients with severe obesity, and the role of WC in predicting POAF in this population. Methods: Our cohort included 7,995 patients undergoing isolated CABG (2006-19). Patients with atrial fibrillation were excluded. POAF risk was compared across BMI and WC categories. In patients with severe obesity, the association of a 10 cm incremental in WC with POAF risk was assessed. We used a log-binomial regression model. Results are presented as adjusted relative risks (aRR) with 95% confidence intervals (CI). Results: 763 (9.5%) patients had a BMI ≥ 35 kg/m 2 . Mean BMI was 38.5 ± 3.6 kg/m 2 and WC was 123.4 ± 10.8 cm. The severe obesity group was younger (63 ± 9 vs. 67 ± 9 years, p <0.01) and had a higher proportion of females (28 vs. 21%, p <0.01) compared to normal BMI. More patients with severe obesity developed POAF (37 vs. 29%, aRR: 1.52 [95%CI 1.36-1.72], p <0.01). aRRs of POAF according to BMI and WC categories are presented in Table 1. Independently of BMI, every 10 cm increment in WC among patients with severe obesity was associated with an increased risk of POAF (aRR: 1.17 [95%CI 1.09-1.25], p <0.01). Conclusions: POAF after CABG is prevalent in patients with severe obesity. Our results showed a gradient of increasing POAF risk with increasing BMI and WC. In patients with severe obesity, WC independently provided additional prognostic value beyond BMI. Since POAF is associated with adverse long-term outcomes, WC could be targeted for the development of preventive strategies.

Abstract 12958: Temporal Association of Systemic Inflammatory Biomarkers With Incidence of Postoperative Atrial Fibrillation After Botulinum Toxin Type A Administration in Epicardial Fat Pads

Background: A one-time injection of botulinum toxin type A (BoNT/A) in epicardial fat pads was evaluated for post-operative atrial fibrillation (POAF) in patients undergoing open-chest cardiac surgery in the Ph2 NOVA trial. Treatment with 125U BoNT/A numerically reduced the incidence of POAF in the mITT (36.5% vs 46.1%) and CABG populations (28.4% vs 40.0%), with statistical significance observed in the CABG + ≥65 years subgroup (27.5% vs 56.4%; P <0.01). No significant reduction was observed in the 250U group vs placebo. Purpose: Explore systemic inflammatory biomarker changes after treatment with BoNT/A and the temporal relation to incidence of POAF. Methods: This analysis included 308 patients who received 125U BoNT/A (n=103), 250U BoNT/A (n=103), or placebo (n=102). Subgroup analysis was done for CABG (n=198), age ≥65 years (n=185), and CABG + ≥65 years (n=118). Serum samples were collected preoperatively prior to dosing on Day 1, then post-treatment on Days 2-4 to test for IL-6, IL-10, and hsCRP. A 2-sample t test was used for mean concentrations and a linear mixed model was used for fold change (FC) from baseline. Results: Baseline levels of IL-6, IL-10, and hsCRP were similar between treatment groups. Reduction of IL-6 (45.7 ± 4.4 vs 62.4 ± 5.8 pg/mL, P <0.05; 10.8 vs 15.9 FC, P <0.01) and IL-10 (1.49 ± 0.13 vs 2.04 ± 0.24 pg/mL, P <0.05; 1.96 vs 2.66 FC, P <0.01) was most significant on Day 2 in CABG patients treated with 125U vs placebo, which aligns with the highest rate and risk of POAF (Figure 1). Mean hsCRP was most significantly reduced on Day 4 in the 250U group among CABG patients (193 ± 8 vs 227 ± 10 mg/dL, P <0.01) followed by 125U vs placebo (196 ± 10 vs 227 ± 10 mg/dL, P <0.05); a similar dose-dependent reduction was observed by FC analysis. Conclusions: Treatment with 125U BoNT/A in cardiac surgery patients lowered the incidence of POAF vs placebo and reduced postoperative systemic IL-6 and IL-10 on Day 2, most significantly in the CABG population.

Prospective Study of Risk Factors for Postoperative Atrial Fibrillation After Cardiac Surgery

IntroductionTo examine risk factors for new-onset postoperative atrial fibrillation (POAF) after cardiac surgery. MethodsPatients enrolled in the Cardiothoracic Surgical Trials Network multicenter, randomized trial of rate control versus rhythm control for POAF were included. Predictors of POAF were determined using multivariable logistic regression. ResultsAmong the 2104 patients who were enrolled preoperatively, 695 developed POAF (33.0%). Rates of POAF were 28.1% after isolated coronary artery bypass grafting (CABG), 33.7% after isolated valve repair or replacement, and 47.3% after CABG plus valve repair or replacement. Baseline characteristics associated with an increased risk of POAF identified on multivariable analysis included older age (odds ratio [OR] 1.57; 95% confidence interval [CI] 1.42-1.73, per 10 y), White race or non-Hispanic ethnicity (OR 1.52; CI: 1.11-2.07), history of heart failure (OR 1.55; CI: 1.16-2.08), and history of hypothyroidism (OR 1.42; CI 1.04-1.94). The type of cardiac procedure was associated with an increased risk of POAF with both isolated valve repair or replacement (OR 1.33, CI 1.08-1.64) and combined CABG plus valve repair or replacement (OR 1.64, CI 1.24-2.17) having increased risk of POAF compared to isolated CABG. No preoperative cardiac medication was associated with POAF. ConclusionsIn this prospective cohort of patients, older age, a history of hypothyroidism, a history of heart failure, and valve repair or replacement, with or without CABG, and White non-Hispanic race were associated with an increased risk of POAF.

Risk Scores for Prediction of Postoperative Atrial Fibrillation After Cardiac Surgery: A Systematic Review and Meta-Analysis

Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery and is associated with poor clinical outcomes. The objective of this systematic review and meta-analysis was to assess the performance of risk scores to predict POAF in cardiac surgery patients. We searched MEDLINE, Embase, and Cochrane CENTRAL for studies that developed/evaluated a POAF risk prediction model. Pairs of reviewers independently screened studies and extracted data. We pooled area under the receiver operating curves (AUCs), sensitivity and specificity, and adjusted odds ratios from multivariable regression analyses using the generic inverse variance method and random effects models. Forty-three studies (n=63,847) were included in the quantitative synthesis. Most scores were originally developed for other purposes but evaluated for predicting POAF. Pooled AUC revealed moderate POAF discrimination for the EuroSCORE II (AUC 0.59, 95% confidence interval [CI] 0.54 to 0.65), Society of Thoracic Surgeons (AUC 0.60, 95% CI 0.56 to 0.63), EuroSCORE (AUC 0.63, 95% CI 0.58 to 0.68), CHADS2 (AUC 0.66, 95% CI 0.57 to 0.75), POAF Score (AUC 0.66, 95% CI 0.63 to 0.68), HATCH (AUC 0.67, 95% CI 0.57 to 0.75), CHA2DS2-VASc (AUC 0.68, 95% CI 0.60 to 0.75) and SYNTAX scores (AUC 0.74, 95% CI 0.71 to 0.78). Pooled analyses at specific cutoffs of the CHA2DS2-VASc, CHADS2, HATCH, and POAF scores demonstrated moderate-to-high sensitivity (range 46% to 87%) and low-to-moderate specificity (range 31% to 70%) for POAF prediction. In conclusion, existing clinical risk scores offer at best moderate prediction for POAF after cardiac surgery. Better models are needed to guide POAF risk stratification in cardiac surgery patients.

Characterization of unipolar electrogram morphology: a novel tool for quantifying conduction inhomogeneity.

Areas of conduction inhomogeneity (CI) during sinus rhythm may facilitate the initiation and perpetuation of atrial fibrillation (AF). Currently, no tool is available to quantify the severity of CI. Our aim is to develop and validate a novel tool using unipolar electrograms (EGMs) only to quantify the severity of CI in the atria. Epicardial mapping of the right atrium (RA) and left atrium, including Bachmann's bundle, was performed in 235 patients undergoing coronary artery bypass grafting surgery. Conduction inhomogeneity was defined as the amount of conduction block. Electrograms were classified as single, short, long double (LDP), and fractionated potentials (FPs), and the fractionation duration of non-single potentials was measured. The proportion of low-voltage areas (LVAs, <1 mV) was calculated. Increased CI was associated with decreased potential voltages and increased LVAs, LDPs, and FPs. The Electrical Fingerprint Score consisting of RA EGM features, including LVAs and LDPs, was most accurate in predicting CI severity. The RA Electrical Fingerprint Score demonstrated the highest correlation with the amount of CI in both atria (r = 0.70, P < 0.001). The Electrical Fingerprint Score is a novel tool to quantify the severity of CI using only unipolar EGM characteristics recorded. This tool can be used to stage the degree of conduction abnormalities without constructing spatial activation patterns, potentially enabling early identification of patients at high risk of post-operative AF or selection of the appropriate ablation approach in addition to pulmonary vein isolation at the electrophysiology laboratory.

Incidence, Risk Score Performance, and In-Hospital Outcomes of Postoperative Atrial Fibrillation After Cardiac Surgery.

Postoperative atrial fibrillation (POAF) frequently complicates cardiac surgery. Predicting POAF can guide interventions to prevent its onset. This study assessed the incidence, risk factors, and related adverse outcomes of POAF after cardiac surgery. A cohort of 1,606 patients undergoing cardiac surgery at a tertiary referral center was analyzed. Postoperative AF was defined based on the Society of Thoracic Surgeons' criteria: AF/atrial flutter after operating room exit that either lasted longer than 1 hour or required medical or procedural intervention. Risk factors for POAF were evaluated, and the performance of established risk scores (POAF, HATCH, COM-AF, CHA2DS2-VASc, and Society of Thoracic Surgeons risk scores) in predicting POAF was assessed using discrimination (area under the receiver operator characteristics curve) analysis. The association of POAF with secondary outcomes, including length of hospital stay, ventilator time, and discharge to rehabilitation facilities, was evaluated using adjusted linear and logistic regression models. The incidence of POAF was 32.2% (n = 517). Patients who developed POAF were older, had traditional cardiovascular risk factors and higher Society of Thoracic Surgeons risk scores, and often underwent valve surgery. The POAF risk score demonstrated the highest area under the receiver operator characteristics curve (0.65), but risk scores generally underperformed. Postoperative AF was associated with extended hospital stays, longer ventilator use, and higher likelihood of discharge to rehabilitation facilities (odds ratio, 2.30; 95% CI, 1.73-3.08). This study observed a high incidence of POAF following cardiac surgery and its association with increased morbidity and resource utilization. Accurate POAF prediction remains elusive, emphasizing the need for better risk-prediction methods and tailored interventions to diminish the effect of POAF on patient outcomes.

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.

New-onset postoperative atrial fibrillation after mitral valve surgery: Determinants and the effect on survival

ObjectiveMitral valve surgery (MVS) carries substantial risk of postoperative atrial fibrillation (PAF). Identifying patients who benefit from prophylactic left atrial appendage amputation (LAAA) or maze is ill-defined. To guide such interventions, we determined preoperative predictors of PAF and investigated 3-year survival of patients with PAF. MethodsWe performed a retrospective analysis of patients undergoing isolated MVS (N = 670) between 2011 and 2021. Patients with preoperative atrial fibrillation, LAAA or pulmonary vein isolation were excluded. Patient characteristics were compared between those without PAF and those who developed transient or prolonged PAF. Predictors of any PAF and prolonged PAF were identified using multivariable regression analysis. ResultsIn total, 504 patients without preoperative atrial fibrillation underwent isolated MVS. Of them, 303 patients (60.2%) developed PAF; 138 (27.3%) developed transient and 165 (32.7%) developed prolonged (beyond 30 days) PAF. Patients with PAF were older (65.7 vs 54.3 years, P < .001), with larger left atria (4.8 vs 4.3 cm, P < .001), greater prevalence of hypertension (60% vs 47.8%, P < .05), and were New York Heart Association class III/IV (36% vs 8.5%, P < .001). Independent predictors of PAF included left atria volume index (odds ratio [OR], 1.02; P < .003), older age (OR, 1.04; P < .001), heart failure (OR, 6.73; P < .001), and sternotomy (OR, 2.19; P < .002). Age, heart failure, and sternotomy were independent predictors of prolonged PAF. Patients with PAF had greater mortality at 3 years compared with those without PAF (5.3% vs 0.5%, P < .005). On multivariable analysis, PAF was associated with increased mortality (hazard ratio, 7.81; P < .046). ConclusionsPAF is common after MVS and associated with late mortality. Older age, advanced heart failure, and sternotomy are associated with prolonged PAF. These factors may identify patients who would benefit from prophylactic LAAA or ablation during MVS.

C-reactive protein: perioperative changes and prognostic significance in assessing the risk of atrial fibrillation in patients after coronary bypass surgery

Aim. To study the level of high-sensitivity C-reactive protein (hsCRP) before coronary artery bypass surgery (CABG) and on days 7-10, as well as to assess the association of perioperative changes in hsCRP with the risk of postoperative atrial fibrillation (POAF).Material and methods. The study included 80 patients (71 (88,75%) men) who underwent an elective CABG in Cardiac Surgery Department of Sklifosovsky Research Institute of Emergency Medicine. The first episode of POAF was considered an episode of arrhythmia, registered by electrocardiography (ECG), Holter monitoring (HM) or bedside cardiac monitor in the intensive care unit. Depending on the development of atrial fibrillation in the postoperative period, patients were divided into 2 following groups: patients with POAF (n=20), patients without POAF (n=60). The serum level of hsCRP was studied twice: before surgery and 7-10 after CABG in patients of both groups.Results. Both groups did not differ significantly in the initial concentration of hsCRP (p=0,802). In the postoperative period, patients in both groups showed a significant increase in hsCRP compared with the initial concentration — up to 39,1 [19,6; 64,0] mg/l in the POAF group (p&lt;0,001) and up to 29,3 [19,7; 45,6] mg/l in the group without POAF (p=0,001), but the difference between the groups was not significant (p=0,338). Serum hsCRP concentration at 7-10 days after CABG in patients of both groups was significantly higher than the baseline (p&lt;0,001). However, no association between POAF risk and hsCRP concentration was found (p&gt;0,05).Conclusion. In patients after CABG, on days 7-10, there is a significantly higher level of hsCRP compared with the initial concentration. There were no significant differences in the level of hsCRP between patients with and without POAF. The POAF of is not associated with an initially elevated level of hsCRP and hsCRP level on days 7-10 after CABG.

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.

Abstract P103: Higher Preoperative Plasma Aldosterone Concentrations Are Associated With Elevated Risk Of Atrial Fibrillation After Chronic Total Occlusion Percutaneous Coronary Intervention

Background: Postoperative atrial fibrillation (POAF) is associated with poor outcomes in patients with coronary chronic total occlusions (CTO). Aldosterone is a steroid hormone that regulates fluid and electrolyte homeostasis and is known to increase the risk of proarrhythmia. This study aimed to explore the additional value of preoperative plasma aldosterone levels for predicting POAF after CTO percutaneous coronary intervention (PCI). Methods: We conducted a prospective cohort study involving consecutive patients with a left ventricular ejection fraction (LVEF) greater than 50% requiring CTO-PCI in the First Affiliated Hospital of Chengdu Medical College. Patients were excluded if they had a history of AF, preoperative endocarditis and/or a ventricular assist device. Plasma aldosterone levels, echocardiography and transforming growth factor beta1 (TGF-β1) examination were assessed before percutaneous recanalization. The primary endpoint was the occurrence of POAF within 30 days after percutaneous recanalization. New-onset POAF after CTO-PCI was defined as any episode detected via continuous in-hospital electrocardiogram/telemetry monitoring and documented by a physician in the chart, regardless of duration or need for treatment. Results: Thirty-eight of 268 (14.2%) patients had POAF. Compared with controls, patients experiencing POAF were significantly older, had a higher body mass index, had diabetes and hypertension, and had higher preoperative plasma aldosterone levels. In logistic regression analysis, higher plasma aldosterone levels exhibited 1.75-fold higher odds (95% confidence interval [CI], 1.15-2.32, P=0.004) for the presence of POAF, which was significant in the adjusted model (odds ratio [OR], 1.82 [95% CI, 1.21-2.45], P=0.007). Reverse transcriptase PCR analysis performed on the left atrial appendage and plasma examination revealed that TGF-β1 was activated in POAF patients. Conclusion: Higher plasma aldosterone levels are associated with increased odds for POAF in patients with CTO-PCI, even in the absence of primary aldosteronism, implying that plasma aldosterone levels might be a target for POAF risk stratification after CTO-PCI.

Baseline Intraoperative Left Ventricular Diastolic Function Is Associated with Postoperative Atrial Fibrillation after Cardiac Surgery.

Detailed understanding of the association between intraoperative left atrial and left ventricular diastolic function and postoperative atrial fibrillation is lacking. In this post hoc analysis of the Posterior Left Pericardiotomy for the Prevention of Atrial Fibrillation after Cardiac Surgery (PALACS) trial, we aimed to evaluate the association of intraoperative left atrial and left ventricular diastolic function as assessed by transesophageal echocardiography (TEE) with postoperative atrial fibrillation. PALACS patients with available intraoperative TEE data (n = 402 of 420; 95.7%) were included in this cohort study. We tested the hypotheses that preoperative left atrial size and function, left ventricular diastolic function, and their intraoperative changes were associated with postoperative atrial fibrillation. Normal left ventricular diastolic function was graded as 0 and with lateral e' velocity 10 cm/s or greater. Diastolic dysfunction was defined as lateral e' less than 10 cm/s using E/e' cutoffs of grade 1, E/e' 8 or less; grade, 2 E/e' 9 to 12; and grade 3, E/e' 13 or greater, along with two criteria based on mitral inflow and pulmonary wave flow velocities. A total of 230 of 402 patients (57.2%) had intraoperative diastolic dysfunction. Posterior pericardiotomy intervention was not significantly different between the two groups. A total of 99 of 402 patients (24.6%) developed postoperative atrial fibrillation. Patients who developed postoperative atrial fibrillation more frequently had abnormal left ventricular diastolic function compared to patients who did not develop postoperative atrial fibrillation (75.0% [n = 161 of 303] vs. 57.5% [n = 69 of 99]; P = 0.004). Of the left atrial size and function parameters, only delta left atrial area, defined as presternotomy minus post-chest closure measurement, was significantly different in the no postoperative atrial fibrillation versus postoperative atrial fibrillation groups on univariate analysis (-2.1 cm2 [interquartile range, -5.1 to 1.0] vs. 0.1 [interquartile range, -4.0 to 4.8]; P = 0.028). At multivariable analysis, baseline abnormal left ventricular diastolic function (odds ratio, 2.02; 95% CI, 1.15 to 3.63; P = 0.016) and pericardiotomy intervention (odds ratio, 0.46; 95% CI, 0.27 to 0.78, P = 0.004) were the only covariates independently associated with postoperative atrial fibrillation. Baseline preoperative left ventricular diastolic dysfunction on TEE, not left atrial size or function, is independently associated with postoperative atrial fibrillation. Further studies are needed to test if interventions aimed at optimizing intraoperative left ventricular diastolic function during cardiac surgery may reduce the risk of postoperative atrial fibrillation.

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.

Auditing the safety and efficacy of interventional septal reduction therapies in hypertrophic obstructive cardiomyopathy at a specialized tertiary centre

Abstract Funding Acknowledgements Type of funding sources: None. Background Hypertrophic cardiomyopathy (HCM) is a recognized cause of sudden cardiac death and dysrhythmias. Patients with HCM and marked left ventricular outflow tract obstruction (LVOTO) may benefit from invasive therapies such as septal myectomy or alcohol septal ablation (ASA) (1). This study aimed to compare patient outcomes post-ASA and post-septal myectomy within a specialized tertiary centre. Purpose To establish the efficacy and safety outcomes of septal reduction therapies. Postoperative conduction abnormalities are the most common long-term postoperative complications in this population (2); however, specific patient outcomes at our tertiary heart centre were previously unknown. Methods This retrospective analysis included patients who underwent ASA (n= 66) or septal myectomy (n=151) between 2015 and 2021. Ethical approval was obtained before commencing the study. Two independent investigators extracted the preoperative and postoperative data from echocardiograms, electrocardiograms, clinic letters, and discharge forms. Normally distributed variables were reported as mean and standard deviation and analysed using an unpaired T-test with Welch's correction. Non-normally distributed variables were reported as median and interquartile range and analysed using the Mann-Whitney U test. Results The mean follow-up time was 2.69 ±1.37 years in the ASA cohort and 1.38 ±1.18 years in the myectomy cohort. There were no differences in gender or ethnic composition; however, on average, patients in the ASA cohort were 10.40 ± 1.82 years older than those in the myectomy cohort (95% CI: 13.99 to 6.81, p&amp;lt; 0.0001). Significant improvements in New York Heart Association (NYHA) class occurred across both cohorts (p&amp;lt; 0.0001). Post-ASA resting LVOT gradients decreased from 54.00 to 13.00 mmHg (95% CI: -45.00 to -21.00, p&amp;lt; 0.0001). Post-myectomy resting LVOT gradients decreased from 60.00 to 4.90 mmHg (95% CI: -57.00 to -41.00, p&amp;lt; 0.0001) and were significantly lower than post-ASA (p= 0.0007). In addition, re-intervention rates were higher post-ASA compared to post-myectomy 40% vs 1.32% respectively, (p&amp;lt; 0.0001). ASA also carried a greater risk of permanent pacemaker implantation 18% vs. 8% (p=0.0270), complete heart block 22% vs. 6% (p= 0.0016), and right bundle branch block 28% vs 0% (p&amp;lt; 0.0001) compared to septal myectomy. In contrast, septal myectomy had a greater risk of postoperative atrial fibrillation 20% vs 1.5% (p= 0.0004), and left bundle branch block 60% vs 7% (p&amp;lt; 0.0001) compared to ASA. Perioperative mortality was 0 (0%) in both cohorts. Conclusion In conclusion, both interventions were safe and provided significant symptomatic relief and effective gradient reduction. However, conduction abnormalities remain a considerable risk of septal reduction therapies and may contribute to patient morbidity. More research is needed to minimize intervention risks and further improve patient outcomes.

Clinical Profiling and Biomarkers for Post-Operative Atrial Fibrillation Prediction in Patients Undergoing Cardiac Surgery.

Post-operative atrial fibrillation (POAF) is the most common arrhythmia in the post-operative period after cardiac surgery. We aim to investigate the main clinical, local, and/or peripheral biochemical and molecular predictors for POAF in patients undergoing coronary and/or valve surgery. Between August 2020 and September 2022, consecutive patients undergoing cardiac surgery without previous history of AF were studied. Clinical variables, plasma, and biological tissues (epicardial and subcutaneous fat) were obtained before surgery. Pre-operative markers associated with inflammation, adiposity, atrial stretch, and fibrosis were analyzed on peripheral and local samples with multiplex assay and real-time PCR. Univariate and multivariate logistic regression analyses were performed in order to identify the main predictors for POAF. Patients were followed-up until hospital discharge. Out of 123 consecutive patients without prior AF, 43 (34.9%) developed POAF during hospitalization. The main predictors were cardiopulmonary bypass time (odds ratio (OR) 1.008 (95% confidence interval (CI), 1.002-1.013), p = 0.005), and plasma pre-operative orosomucoid levels (OR 1.008 (1.206-5.761). After studying differences regarding sex, orosomucoid was the best predictor for POAF in women (OR 2.639 (95% CI, 1.455-4.788), p = 0.027) but not in men. The results support the pre-operative inflammation pathway as a factor involved in the risk of POAF, mainly in women.

Molecular mechanisms of postoperative atrial fibrillation in patients with obstructive sleep apnea.

Obstructive sleep apnea (OSA) promotes atrial remodeling and fibrosis, providing a substrate for atrial fibrillation (AF). Herein, we investigate the pathophysiological mechanisms of AF in association with OSA in a cohort of cardiac surgery patients. A prospective study including patients undergoing cardiac surgery. Biomarkers reflective of AF pathophysiology (interleukin [IL-6], C-reactive protein [CRP], von Willebrand factor [vWF], N-terminal pro-brain natriuretic peptide [NT-proBNP], high-sensitivity Troponin T [hs-TnT], and Galectin-3 [Gal-3]) was assessed by functional or immunological assays. miRNAs involved in AF were analyzed by reverse transcription-polymerase chain reaction (RT-PCR). Using atrial tissue samples, fibrosis was assessed by Masson's trichrome. Connexin 40 and 43 (Cx40; Cx43) were evaluated by immunolabeling. Fifty-six patients (15 with OSA and 41 non-OSA) were included in this hypothesis-generating pilot study. OSA group had a higher incidence of postoperative AF (POAF) (46.7% vs. 19.5%; p = .042), presented an increased risk of POAF (OR 3.61, 95% CI 1.01-12.92), and had significantly higher baseline levels of NT-proBNP (p = .044), vWF (p = .049), Gal-3 (p = .009), IL-6 (p = .002), and CRP (p = .003). This group presented lower levels of miR-21 and miR-208 (both p < .05). Also, lower Cx40 levels in POAF and/or OSA patients (50.0% vs. 81.8%, p = .033) were found. The presence of interstitial fibrosis (according to myocardial collagen by Masson's trichrome) was raised in OSA patients (86.7% vs. 53.7%, p = .024). Several biomarkers and miRNAs involved in inflammation and fibrosis were dysregulated in OSA patients, which together with a higher degree of interstitial fibrosis, altered miRNA, and Cxs expression predisposes to the development of a substrate that increases the AF risk.