postoperative atrial fibrillation: prophylaxis and...

Postoperative Atrial Fibrillation:

Prophylaxis and Treatment

Ralph J. Damiano Jr.

John Shoenberg Professor of Surgery

Chief, Cardiac Surgery

Postoperative Atrial Fibrillation:

Prophylaxis and Treatment

Ralph J. Damiano Jr.

John Shoenberg Professor of Surgery

Chief, Cardiac SurgeryChief, Cardiac Surgery

Vice Chairman, Department of Surgery

Barnes Jewish Hospital

Washington University School of MedicineSt. Louis, Missouri USA

Chief, Cardiac Surgery

Vice Chairman, Department of Surgery

Barnes Jewish Hospital

Washington University School of MedicineSt. Louis, Missouri USA

Allied Health Professional SymposiumAllied Health Professional SymposiumAATS Annual MetingAATS Annual Meting

April 28, 2012April 28, 2012

DisclosureDisclosure

�� Consultant for AtriCure, MedtronicConsultant for AtriCure, Medtronic

�� Research and educational grants over the last 2 years:Research and educational grants over the last 2 years:

��AtriCureAtriCure

EdwardsEdwards��EdwardsEdwards

Postoperative Atrial FibrillationPostoperative Atrial Fibrillation

�� Remains the most common complication following Remains the most common complication following

cardiac surgery, the incidence is unchanged despite cardiac surgery, the incidence is unchanged despite

decades of basic and clinical researchdecades of basic and clinical research

�� Significant cause of morbidity leading to increased Significant cause of morbidity leading to increased

utilization of healthcare resourcesutilization of healthcare resources�� ArankiAranki SF, SF, ShaweShawe DP, Adams DH et al. Circulation 1996; 94: 390DP, Adams DH et al. Circulation 1996; 94: 390--397.397.

�� Lauer MS, Eagle KA, Buckley MJ, Lauer MS, Eagle KA, Buckley MJ, SanctisSanctis RW. Pro RW. Pro CardiovascCardiovasc DisDis 1989; 5:3671989; 5:367--368.368.

IncidenceIncidence

�� MetaMeta--analysis of 24 randomized controlled trials found an analysis of 24 randomized controlled trials found an

incidence of 26%incidence of 26%�� Andrews TC, Andrews TC, ReimoldReimold SC, Berlin JA, SC, Berlin JA, AntmanAntman EM. Circulation 1991; 81: III236EM. Circulation 1991; 81: III236--III244.III244.

�� Higher incidence after valve surgery and combined valve Higher incidence after valve surgery and combined valve

surgery and coronary artery bypass graftingsurgery and coronary artery bypass graftingsurgery and coronary artery bypass graftingsurgery and coronary artery bypass grafting

�� Lowest rates seen after transplantationLowest rates seen after transplantation�� Creswell LL, Creswell LL, SchuesslerSchuessler RB, RB, RosenbloomRosenbloom M, Cox JL. Ann M, Cox JL. Ann ThoracThorac SurgSurg 1993; 56:5391993; 56:539--549.549.

�� The incidence at Washington University has been 30% over The incidence at Washington University has been 30% over

the last 20 years.the last 20 years.

�� No change in incidence despite widespread use of beta No change in incidence despite widespread use of beta

blockers and statinsblockers and statins

Shen J et alShen J et al

J Thorac Cardiovasc Surg 2011;141:559J Thorac Cardiovasc Surg 2011;141:559--570570

PathophysiologyPathophysiology

�� The underlying pathophysiology of postoperative The underlying pathophysiology of postoperative

atrial fibrillation remains poorly defined.atrial fibrillation remains poorly defined.

�� Various factors have been implicated.Various factors have been implicated.�� Various factors have been implicated.Various factors have been implicated.

�� InflammationInflammation

�� Autonomic dysfunctionAutonomic dysfunction

�� Ventricular dysfunctionVentricular dysfunction

�� CardioplegiaCardioplegia

�� Atrial swelling or stretchAtrial swelling or stretch

�� ReninRenin--angiotensinangiotensin--aldosterone systemaldosterone system

InflammationInflammation

�� The degree of atrial inflammation has been shown by our The degree of atrial inflammation has been shown by our

group to be associated with a proportional increase in the group to be associated with a proportional increase in the

inhomogeneity of atrial conduction and AF duration in an inhomogeneity of atrial conduction and AF duration in an

animal model.animal model.

�� This may be a factor in the pathogenesis of early This may be a factor in the pathogenesis of early

postoperative AF. postoperative AF.

�� AntiAnti--inflammatory therapy may have the potential to inflammatory therapy may have the potential to

decrease the incidence of AF after cardiac surgery.decrease the incidence of AF after cardiac surgery.

Ishii Y, et al.Ishii Y, et al.

Circulation 2005; 111:2881Circulation 2005; 111:2881--2888.2888.

Activation Map of Lateral RAActivation Map of Lateral RA

■■ AnesthesiaAnesthesia

�� HomogeneouslyHomogeneously

■■ PericardiotomyPericardiotomy

�� Mildly inhomogeneousMildly inhomogeneous

■■ AtriotomyAtriotomy

Anesthesia Pericardiotomy

■■ AtriotomyAtriotomy

�� Greater inhomogeneityGreater inhomogeneity

■■ Atriotomy+SteroidsAtriotomy+Steroids

�� Homogeneously parallel to Homogeneously parallel to

atrial incisionatrial incision

Ishii Y, et al. Circ 2005; 111:2881-2888.

Atriotomy+SteroidsAtriotomy

Role of Inflammation in Postoperative AF

IshiiIshii, et al, et al

Circulation 2005;111:2881Circulation 2005;111:2881--28882888

60

80

100

Pr [AF] %

p = 0.012

AF InducibilityAF Inducibility

0.0 0.5 1.0 1.5 2.0 2.5

MPO (DELTA OD/min/mg protein)

0

20

40Pr [AF] %

Predictors of PostoperativePostoperative AFPredictors of PostoperativePostoperative AF

� Numerous risk factors have been identified for the

development of atrial fibrillation.

� Age ( >70, OR=5.6)

� Male gender

Race (OR=1.6)

� Numerous risk factors have been identified for the

development of atrial fibrillation.

� Age ( >70, OR=5.6)

� Male gender

Race (OR=1.6)� Race (OR=1.6)

� Hypertension(OR=1.2)

� History of previous AF

� Redo surgery

� Congestive heart failure (OR=1.3)

� Valvular heart disease (AoV OR=1.5, MitV OR=1.9)

� Left atrial enlargement

� Race (OR=1.6)

� Hypertension(OR=1.2)

� History of previous AF

� Redo surgery

� Congestive heart failure (OR=1.3)

� Valvular heart disease (AoV OR=1.5, MitV OR=1.9)

� Left atrial enlargement

Age and Incidence of Postoperative AFAge and Incidence of Postoperative AF

Shen J et alShen J et al

J Thorac Cardiovasc Surg 2011;141:559J Thorac Cardiovasc Surg 2011;141:559--570570

Influence of LA Volume and Age on the Incidence of

Postoperative AF

OsranekOsranek M, et alM, et al

J Am Coll J Am Coll CardiolCardiol 2006;48:7792006;48:779--798798

Predictors of PostoperativePostoperative AFPredictors of PostoperativePostoperative AF

� Numerous other preoperative risk factors have been identified

for the development of atrial fibrillation including:

� Chronic obstructive pulmonary disease (OR=1.4)

� Peripheral vascular disease (OR=1.3)

Renal insufficiency (OR=1.3)

� Numerous other preoperative risk factors have been identified

for the development of atrial fibrillation including:

� Chronic obstructive pulmonary disease (OR=1.4)

� Peripheral vascular disease (OR=1.3)

Renal insufficiency (OR=1.3)� Renal insufficiency (OR=1.3)

� Obesity

� Left ventricular hypertrophy

� Right coronary disease

� Renal insufficiency (OR=1.3)

� Obesity

� Left ventricular hypertrophy

� Right coronary disease

. . . .

Postoperative Predictors of AFPostoperative Predictors of AF

�� In addition to preoperative risk factors, complications In addition to preoperative risk factors, complications following cardiac surgery have been shown to following cardiac surgery have been shown to increase the risk of postoperative AF.increase the risk of postoperative AF.�� Myocardial infarctionMyocardial infarction

�� Persistent congestive heart failurePersistent congestive heart failure

Respiratory failureRespiratory failure�� Respiratory failureRespiratory failure

�� InfectionInfection

�� Renal failureRenal failure

�� Cardiac arrestCardiac arrest

Likosky DS, Leavitt BJ, Marrin CA et al. Ann Thorac Surg 2003; 76:428-435.Likosky DS, Leavitt BJ, Marrin CA et al. Ann Thorac Surg 2003; 76:428-435.

Timing of Postoperative AFTiming of Postoperative AFTiming of Postoperative AFTiming of Postoperative AF

Mathew JP, Fontes ML, Tudor IC et al. JAMA 2004; 291: 1720-1729.Mathew JP, Fontes ML, Tudor IC et al. JAMA 2004; 291: 1720-1729.

� Atrial fibrillation was most common on postoperative day 2

� Recurrence was most common on postoperative day 3

� More than 60% of initial recurrence occurring within 2 days of first onset

� Only 22% of patients (326/1503) experienced more than 2 episodes.

� Atrial fibrillation was most common on postoperative day 2

� Recurrence was most common on postoperative day 3

� More than 60% of initial recurrence occurring within 2 days of first onset

� Only 22% of patients (326/1503) experienced more than 2 episodes.

Postoperative Atrial Fibrillation: Postoperative Atrial Fibrillation:

Morbidity and MortalityMorbidity and Mortality

�� Often thought of as a benign arrhythmia, however, this is not Often thought of as a benign arrhythmia, however, this is not

true.true.

�� Studies have shown increased early and late mortality, Studies have shown increased early and late mortality,

stroke, and prolonged hospital length of stay.stroke, and prolonged hospital length of stay.�� AlmassiAlmassi GH, GH, SchowalterSchowalter T, T, NicolosiNicolosi AC et al. Ann AC et al. Ann SurgSurg 1997; 226: 5011997; 226: 501--513.513.AlmassiAlmassi GH, GH, SchowalterSchowalter T, T, NicolosiNicolosi AC et al. Ann AC et al. Ann SurgSurg 1997; 226: 5011997; 226: 501--513.513.

�� LikoskyLikosky DS, Leavitt BJ, DS, Leavitt BJ, MarrinMarrin CA et al. Ann CA et al. Ann ThoracThorac SurgSurg 2003; 76:4282003; 76:428--435.435.

�� VillarealVillareal RP, RP, HariharanHariharan R, Liu BC et al. J Am R, Liu BC et al. J Am CollColl CardiolCardiol 2004; 43: 7422004; 43: 742--748.748.

�� BorzakBorzak S, Tisdale JE, S, Tisdale JE, AminAmin NB et al. Chest 1999; 113: 1489NB et al. Chest 1999; 113: 1489--1491.1491.

�� Increased hospital and healthcare costsIncreased hospital and healthcare costs�� LikoskyLikosky DS, Leavitt BJ, DS, Leavitt BJ, MarrinMarrin CA et al. Ann CA et al. Ann ThoracThorac SurgSurg 2003; 76:4282003; 76:428--435.435.

�� Auer J, Weber T, Auer J, Weber T, BerentBerent R et al. J R et al. J CardiovascCardiovasc SurgSurg 2005; 46:5832005; 46:583--588.588.

Postoperative AF:Postoperative AF:

Morbidity and MortalityMorbidity and Mortality

�� 6475 patients undergoing CABG6475 patients undergoing CABG

�� InIn--hospital mortality was increased in hospital mortality was increased in ptspts. with . with

POAF from 3.4 to 7.4% (p=.0007)POAF from 3.4 to 7.4% (p=.0007)

�� POAF was an independent predictor of late POAF was an independent predictor of late �� POAF was an independent predictor of late POAF was an independent predictor of late

mortality (OR 3.4, p=.0018, casemortality (OR 3.4, p=.0018, case--matched group)matched group)

�� Stroke was increased in Stroke was increased in ptspts. with POAF from 1.7 to . with POAF from 1.7 to

5.2% (p<.0001)5.2% (p<.0001)

Villareal et. al.

J Am Coll Cardiol 2004;43:742-48

Preventing Postoperative AFPreventing Postoperative AF

�� Many studies have been conducted examining Many studies have been conducted examining

effective preventative strategies for AF.effective preventative strategies for AF.

�� A metaA meta--analysis demonstrated that prophylactic treatment analysis demonstrated that prophylactic treatment

to decrease postoperative AF reduced hospital stay and to decrease postoperative AF reduced hospital stay and

cost, but had no effect on stroke or mortality.cost, but had no effect on stroke or mortality.cost, but had no effect on stroke or mortality.cost, but had no effect on stroke or mortality.�� Zimmer J, Zimmer J, PezzulloPezzullo J, J, ChoucairChoucair W et al. Am J W et al. Am J CardiolCardiol 2003; 91: 11372003; 91: 1137--1140.1140.

�� Numerous drugs studiedNumerous drugs studied�� BetaBeta--blockers, blockers, AmiodaroneAmiodarone, , SotalolSotalol, Magnesium, Magnesium

�� Other nonOther non--antiarrhythmicsantiarrhythmics

�� StatinsStatins, N, N--3 3 polyunsatruatedpolyunsatruated fatty acids, antifatty acids, anti--inflammatory drugsinflammatory drugs

BetaBeta--blockersblockers

�� MetaMeta--analyses have shown positive effect.analyses have shown positive effect.�� Reduced the incidence of postoperative AF from 33% to 19%.Reduced the incidence of postoperative AF from 33% to 19%.

�� Crystal E, Crystal E, ConolloyConolloy SJ, SJ, SleikSleik K et al. Circulation 2002; 106: 75K et al. Circulation 2002; 106: 75--80.80.

�� Ferguson TB Ferguson TB JrJr, Coombs LP, Peterson ED. JAMA 2002; 287: 2221, Coombs LP, Peterson ED. JAMA 2002; 287: 2221--2227.2227.

Added benefit of reducing Added benefit of reducing perioperativeperioperative mortalitymortality�� Added benefit of reducing Added benefit of reducing perioperativeperioperative mortalitymortality�� Ferguson TB Ferguson TB JrJr, Coombs LP, Peterson ED. JAMA 2002; 287: 2221, Coombs LP, Peterson ED. JAMA 2002; 287: 2221--2227.2227.

�� Current AHA guidelines strongly recommend Current AHA guidelines strongly recommend

preoperative and postoperative betapreoperative and postoperative beta--blocker therapy blocker therapy

for patients undergoing coronary artery bypass for patients undergoing coronary artery bypass

grafting to prevent atrial fibrillation.grafting to prevent atrial fibrillation.

AmiodaroneAmiodarone

�� Largest trial of amiodarone prophylaxis showed that it was Largest trial of amiodarone prophylaxis showed that it was

effective and safe, and had a benefit over the use of betaeffective and safe, and had a benefit over the use of beta--

blockers alone.blockers alone.�� Mitchell LB, Mitchell LB, ExnerExner DV, Wyse DG et al. JAMA 2005; 294: 3093DV, Wyse DG et al. JAMA 2005; 294: 3093--3100.3100.

Benefit of combined oral and intravenous Benefit of combined oral and intravenous amiodaroneamiodarone versus versus �� Benefit of combined oral and intravenous Benefit of combined oral and intravenous amiodaroneamiodarone versus versus

placebo alone (22% vs. 39% of patients) demonstrated in placebo alone (22% vs. 39% of patients) demonstrated in

AFIST II trialAFIST II trial�� White CM, Caron MF, White CM, Caron MF, KalusKalus JS et al. Circulation 2003; 108: II200JS et al. Circulation 2003; 108: II200--II206.II206.

�� Only drug shown to have effect on reducing incidence of Only drug shown to have effect on reducing incidence of

postoperative strokepostoperative stroke�� Burgess DC, Burgess DC, KilbornKilborn MJ, MJ, KeechKeech AC. AC. EurEur Heart J 2006; 27: 2846Heart J 2006; 27: 2846--2857.2857.


�� Well studied in multiple metaWell studied in multiple meta--analysesanalyses

�� Effective despite a wide variation in dosing, scheduling, Effective despite a wide variation in dosing, scheduling,

and route.and route.�� Burgess DC, Burgess DC, KilbornMJKilbornMJ, , KeechKeech AC. AC. EurEur Heart J 2006; 27: 2846Heart J 2006; 27: 2846--2857.2857.

�� Crystal E, Connolly SJ, Crystal E, Connolly SJ, SleikSleik K et al. Circulation 2002; 106:75K et al. Circulation 2002; 106:75--80.80.Crystal E, Connolly SJ, Crystal E, Connolly SJ, SleikSleik K et al. Circulation 2002; 106:75K et al. Circulation 2002; 106:75--80.80.

�� No significant difference found between high and low No significant difference found between high and low

dose regiments, or between preoperative and dose regiments, or between preoperative and

postoperative initiation of treatmentpostoperative initiation of treatment�� Buckley MS, Nolan PE Jr., Slack MK et al. Pharmacotherapy 2007; 27: 360Buckley MS, Nolan PE Jr., Slack MK et al. Pharmacotherapy 2007; 27: 360--368.368.

Other TreatmentsOther Treatments

�� Numerous other treatments have been tested for the Numerous other treatments have been tested for the

prevention of postoperative AFprevention of postoperative AF

�� Include sotalol, magnesium, statins, NInclude sotalol, magnesium, statins, N--3 polyunsaturated 3 polyunsaturated

fatty acids , antifatty acids , anti--inflammatory drugs, temporary pacinginflammatory drugs, temporary pacingfatty acids , antifatty acids , anti--inflammatory drugs, temporary pacinginflammatory drugs, temporary pacing

�� None of these treatments have been proven to be effective None of these treatments have been proven to be effective

with the same robustness of amiodarone or betawith the same robustness of amiodarone or beta--blockers blockers

and the data have been sometimes conflicting.and the data have been sometimes conflicting.

Management of Postoperative Atrial Management of Postoperative Atrial

FibrillationFibrillation

��GoalsGoals�� Assess for hemodynamic instabilityAssess for hemodynamic instability

Differentiate atrial fibrillation from atrial flutterDifferentiate atrial fibrillation from atrial flutter�� Differentiate atrial fibrillation from atrial flutterDifferentiate atrial fibrillation from atrial flutter

�� Rate versus rhythm controlRate versus rhythm control

HemodynamicallyHemodynamically Unstable PatientsUnstable Patients

�� Electrical Electrical cardioversioncardioversion is the mainstay of is the mainstay of

treatmenttreatment

�� SemiSemi--elective cardioversion protocol at Washington elective cardioversion protocol at Washington

UniversityUniversity

�� Contact the critical care physician or Contact the critical care physician or electrophysiologistelectrophysiologist

�� NPO for 4NPO for 4--6 hours6 hours

�� Consider IV Consider IV midazolammidazolam or anesthetic agentor anesthetic agent

�� Check KCheck K++, Mg, Mg2+2+, , digoxindigoxin levelslevels

Atrial FlutterAtrial Flutter

�� Diagnosis of atrial flutter is best made by Diagnosis of atrial flutter is best made by

obtaining an atrial electrogram.obtaining an atrial electrogram.

Atrial epicardial pacing wires

Atrial Flutter

Atrial FlutterAtrial Flutter

�� In patients that have atrial flutter, consider In patients that have atrial flutter, consider

rapid atrial pacing.rapid atrial pacing.

�� Begin burst pacing at twice diastolic threshold and a Begin burst pacing at twice diastolic threshold and a

rate 10% above the flutter cycle length. Increase in rate 10% above the flutter cycle length. Increase in rate 10% above the flutter cycle length. Increase in rate 10% above the flutter cycle length. Increase in

increments of 10% until flutter is terminated.increments of 10% until flutter is terminated.

�� If unsuccessful, treat according to atrial If unsuccessful, treat according to atrial

fibrillation protocol.fibrillation protocol.

Atrial Fibrillation

Atrial Fibrillation Treatment GuidelinesAtrial Fibrillation Treatment Guidelines

�� In the hemodynamically stable patient, there is no urgency In the hemodynamically stable patient, there is no urgency

or reason to electrically cardiovert.or reason to electrically cardiovert.�� Ensure SEnsure SppOO22 > 92%> 92%

�� Correct profound anemiaCorrect profound anemia

Supplement KSupplement K++, Mg, Mg2+2+�� Supplement KSupplement K++, Mg, Mg2+2+

�� First goal is to control the heart rate.First goal is to control the heart rate.

�� Goal to decrease the heart rate below 100Goal to decrease the heart rate below 100

Atrial Fibrillation Rate ControlAtrial Fibrillation Rate Control

�� For patients with preserved EF (>30%)For patients with preserved EF (>30%)

�� DiltiazemDiltiazem 5mg IV test dose5mg IV test dose

�� If tolerated, give 0.25mg/kg IV over 3 minutesIf tolerated, give 0.25mg/kg IV over 3 minutes

�� If effective, begin 5If effective, begin 5--10mg/hr IV infusion10mg/hr IV infusion

��May increase in 5mg/hr increments up to 20mg/hrMay increase in 5mg/hr increments up to 20mg/hr��May increase in 5mg/hr increments up to 20mg/hrMay increase in 5mg/hr increments up to 20mg/hr

�� For patients with poor EF (<30%)For patients with poor EF (<30%)

�� DigoxinDigoxin loadload

�� 0.5mg IV, followed by 0.25mg IV q4h 0.5mg IV, followed by 0.25mg IV q4h xx 2 doses2 doses

�� Maintenance dose based on renal functionMaintenance dose based on renal function

�� Consider early cardioversionConsider early cardioversion

Rhythm ControlRhythm Control

�� For patients that persist in AF for greater than one hour despite For patients that persist in AF for greater than one hour despite

adequate rate control, consider initiation of rhythm control.adequate rate control, consider initiation of rhythm control.

�� AmiodaroneAmiodarone loadload

�� For patients able to take For patients able to take popo or absorb via NGor absorb via NG

�� 400mg 400mg popo t.i.dt.i.d loading dose x 5 daysloading dose x 5 days�� 400mg 400mg popo t.i.dt.i.d loading dose x 5 daysloading dose x 5 days

�� Reassess for maintenance doseReassess for maintenance dose

�� For patients unable to utilize their GI tractFor patients unable to utilize their GI tract

�� 150mg IV over 10 minutes, then 1mg/min infusion 150mg IV over 10 minutes, then 1mg/min infusion xx 6 hours, 6 hours,

followed by 0.5mg/minfollowed by 0.5mg/min

�� MonitoringMonitoring

�� Initial assessment of Initial assessment of LFT’sLFT’s, and , and TFT’sTFT’s

�� Follow QT intervalFollow QT interval

Contraindications to Contraindications to AmiodaroneAmiodarone

�� ContraindicationsContraindications

�� AllergyAllergy

�� History of toxicityHistory of toxicity

�� Severe pulmonary diseaseSevere pulmonary disease�� Severe pulmonary diseaseSevere pulmonary disease

�� 22ndnd degree Type 2 or 3rd degree heart blockdegree Type 2 or 3rd degree heart block

�� Junctional rhythmJunctional rhythm

�� Severe bradycardiaSevere bradycardia

�� Untreated/uncontrolled thyroid diseaseUntreated/uncontrolled thyroid disease

�� PregnancyPregnancy


�� PrecautionsPrecautions

�� Decrease (halve) Decrease (halve) digoxindigoxin dosedose

�� Decrease (halve) warfarin doseDecrease (halve) warfarin dose

�� Beware additive Beware additive bradycardiabradycardia and AV block with betaand AV block with beta--

blockers and calcium channel blockersblockers and calcium channel blockers

Persistent Atrial FibrillationPersistent Atrial Fibrillation

�� For patients that persist in AF >8 hours despite For patients that persist in AF >8 hours despite

amiodarone therapy, consideration must be given to amiodarone therapy, consideration must be given to

anticoagulation to prevent the complication of stroke.anticoagulation to prevent the complication of stroke.

�� Continue oral amiodaroneContinue oral amiodarone

�� AnticoagulationAnticoagulation

�� Coumadin therapy with intravenous heparin bridgeCoumadin therapy with intravenous heparin bridge

�� Goal INR 2.0Goal INR 2.0--3.03.0

Treatment SummaryTreatment Summary

Ensure SpO2 > 92% with supplemental O2Check K+ and Mg2+. Supplement if necessary.

Is the HR >

100 bpm?

Is the arrhythmia persisting

for 1 hour or recurrent?

Consider initiation

or increase in beta

blocker therapy.

No

Yes

No

Yes

Rate Control for EF >30

Diltiazem load and

maintenance

Amiodarone load and maintenanceIs ejection fraction >

30%?

Rate Control for EF < 30

Digoxin load and

maintenance

Is atrial fibrillation present for >8 hrs?

Continue amiodarone PO.

Consider anticoagulation

(target INR 2.0-3.0)Is treatment effective?

Contact Surgical MD + Intensivist.

Continue amiodarone

PO at the discretion of

the attending MD.

No

Yes

No

Yes

Yes No

Postoperative AF 1976Postoperative AF 1976--2010:2010:

A persistent problemA persistent problem

Postoperative AF 1976Postoperative AF 1976--2010:2010:

A persistent problemA persistent problem

72 studies Total n=55,885

Persistent Incidence Despite TreatmentPersistent Incidence Despite TreatmentPersistent Incidence Despite TreatmentPersistent Incidence Despite Treatment

�� New onset AF inNew onset AF in 39% of 275 CABG patients despite high 39% of 275 CABG patients despite high

rates of betarates of beta--blocker and blocker and statinstatin use.use.

�� No statisticalNo statistical difference between patients difference between patients with postoperative with postoperative

AF with and without drug treatmentAF with and without drug treatment

Gibson PH, Cuthbertson BH, Croal BL et al. Am J Cardiol 2010; 105: 186-191.Gibson PH, Cuthbertson BH, Croal BL et al. Am J Cardiol 2010; 105: 186-191.

Postoperative Atrial Fibrillation:Postoperative Atrial Fibrillation:

ConclusionsConclusions



� Postoperative atrial fibrillation is a common

complication following cardiac surgery.

� Postoperative atrial fibrillation is associated with

� Postoperative atrial fibrillation is a common

complication following cardiac surgery.

� Postoperative atrial fibrillation is associated with � Postoperative atrial fibrillation is associated with

significant morbidity and mortality.

� Prevention of postoperative atrial fibrillation is difficult

despite multiple positive clinical trials with a variety of

drugs.

� Postoperative atrial fibrillation is associated with

significant morbidity and mortality.

� Prevention of postoperative atrial fibrillation is difficult

despite multiple positive clinical trials with a variety of

drugs.





� Successful treatment of postoperative atrial

fibrillation requires both rate and rhythm control.

� Further research is needed to define the mechanism

� Successful treatment of postoperative atrial

fibrillation requires both rate and rhythm control.

� Further research is needed to define the mechanism � Further research is needed to define the mechanism

of postoperative atrial fibrillation to more effectively

prevent it.

� Further research is needed to define the mechanism

of postoperative atrial fibrillation to more effectively

prevent it.

Drug Trials to Prevent Postoperative AFDrug Trials to Prevent Postoperative AFDrug Trials to Prevent Postoperative AFDrug Trials to Prevent Postoperative AF

EXPERIMENTALCONTROL

50

75POAF (%)Observational Studies 30%

Beta Block

ers

Digita

lisMag

nes

ium

Verapa

mil

Sotalol

Amioda

rone

NSAID

Statin

Steroid

DRUG

0

25POAF (%)

62 Studies n=123,659

Type II Atrial Flutter

postoperative atrial fibrillation: prophylaxis and...

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