the impact of atrial fibrillation in cardiac surgery
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THE IMPACT OF ATRIAL FIBRILLATION THE IMPACT OF ATRIAL FIBRILLATION IN CARDIAC SURGERY IN CARDIAC SURGERY
Wim J De Vries.DEPARTMENT CARDIOTHORACIC SURGERYUNIVERSITY OF THE FREE STATEUNIVERSITAS HOSPITAL
? Benign Rhythm ? Malignant Rhythm
THE IMPACT OF ATRIAL FIBRILLATION THE IMPACT OF ATRIAL FIBRILLATION IN CARDIAC SURGERY IN CARDIAC SURGERY
New-onset. postoperative atrial fibrillation occurs in 30% of patients undergoing CABG , with the peak incidence on the second to third postoperative day It is associated with a 2- to 3-fold increase in
postoperative risk for stroke. Patients at risk for postoperative atrial fibrillation have been identified and include those with COPD, proximal right CAD, prolonged cross-clamp time, atrial ischemia, advanced age, and withdrawal of beta-blockers. Identifying at-risk patients and directing treatment to these patients appears to be effective in reducing the incidence of nost-C ABG atrial fibrillation. And thus the morbid complication of postoperative strokes associated with this arrhythmia.Minimally invasive and .Qff pump beating-heart procedures may also reduce the incidence of postoperative atrial fibrillation
Eagle and Guyton et al. 2004
ACC/AHA Practice Guidelines
INTRODUCTIONINTRODUCTION
AIM AND METHODSAIM AND METHODS
AIM
-Incidence of post operative Atrial fibrillation
-Identify patients at risk for Atrial fibrillation
-Morbidity and mortality of Atrial fibrillation
Methods
5 Year period, records of patients were prospectively entered in a Departemental database .
AIM
-Incidence of post operative Atrial fibrillation
-Identify patients a risk for Atrial fibrillation
-Morbidity and mortality of Atrial fibrillation
AIM AND METHODS..AIM AND METHODS..
Total 1022 patients - OPCAB(301) - CABG(721)
STUDY POPULATIONSTUDY POPULATION
Total 1022 patients – OPCAB(29,4%) –CABG(70%)
Males (72%)
STUDY POPULATIONSTUDY POPULATION
Total 1022 patients - OPCAB(301) - CABG(721)
Males 798 – 72%
Age (33-84) Mean 60,5 years
STUDY POPULATIONSTUDY POPULATION
Incidence of Incidence of Atial FibrillationAtial Fibrillation
N = 1022N = 1022.
Total 151 14,7 %
RESULTSRESULTS
Male
Sex Female
Age > 65 Smoking
Obesity
Hypertension COPD
Diabetes
Rhythm Risk NRhythm Risk N %% RRRR OROR
10645
106451286
185180
300128
44135
70,2%29,8%
54,9%26,5%56,9%44,2%
11,9%5,8%
52,9%34,0%13,9%5,2%29%15%
2,3
2,07
1,2
1,25
1,5
2,6
1,9
5,5
3,3
1,6
1,20
2,1
2,8
2,9
P
<0,0001
<0,0001
0,004
0,01
<0,001
0,005
0,0001
151151
151871151871
151871151871151871151871
A-Fib
A-FibSinusA-FibSinus
A-FibSinusA-FibSinusA-FibSinusA-FibSinus
RESULTS..RESULTS..
Renal imp Perif Vasc Pulm Hypert
Previous MI
Angina Unstable
Stable
Rhythm Risk NRhythm Risk N %% RRRR OROR
1131
10214
13
70372134605
91433
43172
7,2%3,5%
6,6%2,4%2,6%1,4%
46,3%42,7%
88%69,4%60,2%49,7%28,4%19,7%
2,07
2,3
1,7
1,08
1,2
1,2
1,4
2,1
5,5
1,8
1,08
3,4
1,5
1,6
P
0,04
0,01
NS
NS
<0,0001
0,01
0,01
151871
151871151871
151871151871151871151871
A-FibSinus
A-FibSinusA-FibSinus
A-FibSinusA-FibSinusA-FibSinusA-FibSinus
RESULTS..RESULTS..
Renal impairm Perif Vascular Pulm Hypert Previous MI
Angina Unstable
Stable
Risk factor A- Fib Sinus Risk factor A- Fib Sinus RRRR OROR
2,07
2,3
1,7
1,08
1,2
1,2
1,4
2,1
5,5
1,8
1,08
3,4
1,5
1,6
P
0,04
0,01
NS
NS
<0,0001
0,01
0,01
3,5%
2,4%
1,4%
42,7%
69,4%
49,7%
19,7%
7,2%
6,6%
2,6%
46,3%
88%
1,2%
1,4%
N=151 N=871
(11)
(10)
(4)
(70)
(134)
(91)
(43)
(31)
(21)
(13)
(372)
(605)
(433)
(172)
%%%%NN NN
RESULTS…RESULTS…
CCS >= III ASA >= III NYHA >= III
Emergent
IABP Eject Frac
Rhythm Risk NRhythm Risk N %% RRRR OROR
82320
108352
65215
238531
115MedMed
54,3%36,7%
71,5%40,4%
43%24%
15,2%9,7%
20,5%13,2%
59% 58%
1,4
1,7
1,7
1,6
1,5
2,04
3,7
2,3
1,7
1,6
P
151871
151871151871
151871151871151871
A-FibSinus
A-FibSinusA-FibSinus
A-FibSinusA-FibSinusA-FibSinus
<0,0001
<0,0001
<0,0001
0,02
0,02
NS
RESULTS….RESULTS….
Vessels Diseased
LAD Right Sx
Left Main
# Dst Anas > 3 Off-Pump On Pump
Perf Time
Rhythm Risk NRhythm Risk N %% RRRR OROR
127531
90413
31213
2473
103374
22129
111(M)104(M)
84%60%
59,6%47,4%
20%24,4%
13,9%8,3%
68,2%42,9%7,3%
17,8%
1,3
1,2
0,83
1,8
1,5
0,4
2,5
1,5
0,52
2,06
2,8
0,36
P
0,0001
0,01
NS
0,006
<0,0001
<0,0001
NS
151871
151871151871
151871151871301721151871
A-FibSinus
A-FibSinusA-FibSinus
A-FibSinusA-FibSinusA-Fib
A-FibSinus
RESULTS….RESULTS….
Hospital Stay A-Fib + Hospital Stay Sinus
Hospital Stay NHospital Stay N %% RRRR OROR
8(Median)6(Median)
P
<0,0001151871
RESULTS…..RESULTS…..
Hospital Stay A-FibHospital Stay Sinus
Stroke A-Fib + Stroke Sinus
Stroke NStroke N %% RRRR OROR
8(Median)6(Median)
6,6%3,05%
P
<0,0001
<0,03
151871
10/15121/871 2,1 2,2
RESULTS……RESULTS……
Hospital Stay A-FibHospital Stay Sinus
Stroke A- Fib + Stroke Sinus
Mortality A- fib + Mortality Sinus
Mortality NMortality N %% RRRR OROR
8(M)6(M)
6,6%2,5%
11%2.4%
P
<0,0001
<0,03
<0,001
151871
10/151 22/871
17/15121/871
2,1
4,6
2,2
5,1
Slide Source:Lipids Onlinewww.lipidsonline.org
Mortality in Mortality in AtrialAtrial FibrillationFibrillation
Stroke
Cardiac
Renal
Pulmonary
Vascular
Infection
Rhythm
Other
Mortality (17/151)
5
3
1
3
1
1
2
1
17
(45%)
(17%)
(5,8%)
(17.6%)
(5,8%)
(5,8%)
(6.2%)
(5,8%)
(11%)
(% )N = 151
45%45%
17%17%
17%17%
Slide Source:Lipids Onlinewww.lipidsonline.org
Mortality Mortality inin Sinus RhythmSinus Rhythm
Stroke
Cardiac
Renal
Pulmonary
Vascular
Infection
Rhythm
Other
Mortality (21/871)
0
8
0
3
3
4
0
2
21
(0%)
(38%)
(0%)
(14%)
(14%)
(19%)
(0%)
(9,5%)
(2,4%)
(% )N = 871
38%38%
14%14%
14 %14 %
19 %
9 %
RISK PATIENTSRISK PATIENTS
Males Age > 65 Years
Peripheral Vasc Dis
Angina
NYHA > III
ASA > III
CCS > III
Emergent
IABP
On-Pump Surgery
OROR
5,5
3,3
5,5
3,4
2,3
3,7
2,04
1,7
1,6
0,36
P
<0,0001
<0,0001
0,01
<0,0001
<0,0001
<0,0001
<0,0001
0,02
0,02
<0,0001
RISK PATIENTS..RISK PATIENTS..
Hypertension Smoking
COPD
Diabetes
Renal Impairment
Obesity
LAD Lesion
Right Lesion
Left Main Disease
# Distal Anastomosis >= 3
OROR
2,17
1,6
2,9
2,5
2,1
1,2
2,5
1,5
2,06
2,8
P
<0,001
<0,004
0,0001
0,03
0,04
0, 01
0,0001
0,01
0,006
<0,0001
Conclusion : Atrial FibrillationConclusion : Atrial Fibrillation
Incidence 14,7%
Mortality 11%
Median hospital stay 8 days Incidence of stroke 6,6 %
Conclusion: Atrial Fibrillation..Conclusion: Atrial Fibrillation..
Atrial Fibrillation is probably a marker of underlying disease Post operatively (Tip of the Iceberg). (Ears of hippopotamus)
Atrial fibrillation
Age
Diabetes
HypertensionOn Pump
Atrial Ischemia
Atrial fibrillation
Age
DiabetesHypertension
On Pump
Atrial Ischemia
MANAGEMENTMANAGEMENT
Identify the risk patients
Atrial fibrillation
Age
Diabetes
Hypertension
On Pump
Atrial Ischemia
Identify the risk patientsNon withdrawal of B Blockers
MANAGEMENT.MANAGEMENT.
Identify the risk patientsNon withdrawal of B BlockersProphylactic use of Amidiarone and or B Blockers
MANAGEMENT..MANAGEMENT..
Identify the risk patientsNon withdrawal of B BlockersProphylactic uses of Amidiorone and B BlockersPost operative overdrive pacing of the atrium
MANAGEMENT…MANAGEMENT…
Identify the risk patientsNon withdrawal of B BlockersProphylactic uses of Amidiarone and B BlockersPost operative pacing of the atriumAggressive Treatment of Atrium Fibrillation Post operative to prevent stroke
MANAGEMENT….MANAGEMENT….
THANK YOU!!!
Ke Ya Kopa!!!
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