Invited commentary

A substantial number of patients without a history of atrial fibrillation who undergo surgery develop one or more episodes of atrial fibrillation in the first few days after the operation. We studied whether postoperative transient atrial fibrillation is a risk factor for future atrial fibrillation, stroke and death. We performed a narrative review of the literature on epidemiology, mechanisms, risk of atrial fibrillation, stroke and death after postoperative atrial fibrillation. We reviewed antithrombotic guidelines on this topic and identified gaps in current management. Patients with postoperative atrial fibrillation are at high risk of developing atrial fibrillation in the long term. Mortality is also increased. Most, but not all observational studies report a higher risk of stroke. The optimal antithrombotic regimen for patients with postoperative atrial fibrillation has not been defined. The role of lifestyle changes and of surgical occlusion of the left atrial appendage in preventing adverse outcomes after postoperative atrial fibrillation is not established. Further studies are warranted to establish the optimal strategy to prevent adverse long-term outcomes after transient, postoperative atrial fibrillation.

Pseudomyxoma Originating from the Interatrial Septum in a Heart Transplant Patient

Managing atrial fibrillation in the CRT patient: Controversy or consensus?

Invited commentary

Atrial fibrillation (AF) is associated with heart failure (HF). However, it is unclear if postoperative AF (POAF) following non-cardiac surgery differs from non-surgical AF in terms of the risk of HF. We compared the long-term rate of incident HF in patients developing new-onset POAF following non-cardiac surgery with patients who did not develop POAF following non-cardiac surgery and patients with non-surgical non-valvular AF (NVAF). Using Danish nationwide registries, all patients aged ≥30 years who developed POAF following non-cardiac surgery (1996-2020) were identified and matched in a 1:3 ratio by age, sex, surgery type (only for the surgery group), selected comorbidities, and inclusion year with patients without POAF following non-cardiac surgery and individuals with NVAF, respectively. A total of 2270 patients with POAF were matched with 6810 patients without POAF following non-cardiac surgery, and 1846 patients with POAF were matched with 5538 patients with NVAF. The median follow-up was 7.2 years. Compared with patients without POAF, those with POAF had a higher associated long-term rate of incident HF (2.6 vs. 1.2 events per 100 person-years; adjusted hazard ratio [HR] 2.39, 95% confidence interval [CI] 2.06-2.78). Compared with individuals with NVAF, patients with POAF did not have a significantly different rate of incident HF (2.7 vs. 3.0 events per 100 person-years; adjusted HR 0.89, 95% CI 0.78-1.03). Patients with new-onset POAF following non-cardiac surgery had a higher associated long-term rate of incident HF compared to those without POAF, with no significant difference in the rate of incident HF when compared to patients with NVAF.

To predict the possibility of postoperative atrial fibrillation (AF) with mitral annular plane systolic excursion (MAPSE) measurement, which is acheap, reproducible echocardiographic method and to monitor these patients more closely and to evaluate them more effectively postoperatively. 247 patients scheduled for coronary artery bypass surgery were evaluated and 200 patients were included in the study.The enrolled patients were classified into the two groups according to the occurrence of postoperative AF or maintained sinus rhythm after coronary artery bypass surgery (normal sinus rhythm [NSR] group vs. AF group).The clinical and demographic data of all the patients were recorded on admission. Two-dimensional transthoracic echocardiography (TTE) was performed prior to elective surgery. Postoperative new onset AF occurred in 37 (18.5%) patients. In the multivariate logistic regression analysis carried out after the formation of the model based on the parameters related to AF development, the relationships with white blood cell count, LAd and MAPSE were observed to be prevalent.When MAPSE, which is aparameter used to predict the development of postoperative atrial fibrillation, was compared in the ROC analysis, the area under the curve was found to be 0.831, 95% CI lower-95% CI upper (0.761-0.901) (p<0.001).The distinguishing MAPSE value in predicting postoperative atrial fibrillation development was found to be 11.6 (sensitivity: 90%, specificity: 81%). We showed that MAPSE could play arole in determining postoperative atrial fibrillation development after coronary artery bypass surgery (Tab. 2, Fig. 2, Ref. 28).

Postoperative atrial fibrillation (AF) is the most common arrhythmia that occurs after both cardiac and noncardiac surgery. It is associated with an increased morbidity, longer hospital stay and higher hospital costs. In addition, one of the most important clinical consequences of postoperative AF might be an increased incidence of perioperative stroke.1) There have been many investigations on the incidence, predictors, prophylactic strategies, and management of postoperative AF in patients undergoing cardiothoracic surgery. However, few studies have investigated the incidence and consequences of AF after noncardiothoracic surgery. Refer to the page 100-104 New onset AF after cardiac surgery has been reported to occur in 12 to 40 percent of patients after coronary artery bypass surgery, and the rate is even higher after valve replacement surgery, as high as 60%.2) Predictors associated with an increased risk of postoperative AF, after cardiac surgery, include advanced age, postoperative electrolyte shifts, pericarditis, a history of preoperative AF, a history of congestive heart failure, and chronic obstructive pulmonary disease. Focusing on the incidence and risk factors associated with new onset AF after thoracic (noncardiac) surgery, Vaporciyan and colleagues reported on 2,588 patients and found that the overall incidence of postoperative AF was 12.3%, somewhat lower than that with cardiac surgery; this is consistent with the results of previous reports.3),4) Significant multivariate predictors of AF after thoracic surgery include a male gender, older patient age, history of congestive heart failure, history of arrhythmias, and history of peripheral vascular disease.5) New onset AF, after cardiac and thoracic surgery, is likely triggered by direct intrathoracic stimulation or atrial irritation. It is, therefore, not surprising that the incidence of AF has been found to be lower when surgery does not involve the thorax. In one prospective series of 916 patients over 40 years of age undergoing major noncardiothoracic surgery, the incidence of AF was 2.5%;6) another more recently published study reported much lower incidence, 0.37%.7) Sohn and colleagues added and extended the observations on the topic of AF after noncardiothoracic surgery in this issue of the journal. They report the incidence of postoperative AF after noncardiothoracic surgery was 0.39%, and found that it was a relatively rare complication; it was associated with older age, and emergency surgery, and it extended the hospital stay. Their observations of significant multivariate predictors are different from those reported by Vaporciyan and colleagues. However, diverse patient groups were studied and different cardiac monitoring was used. Therefore, interpretation of the results should be made with consideration of the differences between the studies. The clinicians, especially cardiologists who are likely to care for patients prone to postoperative cardiac complications, consider which patients might benefit from prophylactic strategies. Prospective randomized trials have examined the utility of variety of pharmacological agents and nonpharmacological methods for prophylaxis in patients undergoing cardiothoracic surgery. Although the results have been conflicting, most investigators would agree that β-blockers can serve as effective prophylactic treatment with amiodarone and sotalol as alternative medications. It is uncertain whether such prophylactic medication would be effective in patients undergoing noncardiothoracic surgery because the mechanism of the postoperative AF might be somewhat different. If postoperative AF results from a preexisting electrophysiological substrate with a superimposed trigger, the latter factor might be more important in noncardiothoracic surgery. Therefore, extrapolation of the prophylactic strategies used in patients undergoing cardiothoracic surgery to the entire population of patients undergoing noncardiac surgery may not be warranted.8) Although most episodes of postoperative AF are self-limited, the natural course of postoperative AF after noncardiothoracic surgery should be defined. AF persisting for longer than 48 hours is associated with an increased risk of stroke or transient ischemic attack. Thus, after 48 hours of AF, anticoagulation should be considered, weighing the potential benefits against the risk of postoperative bleeding.9) The article reported by Sohn and colleagues raises concern with regard to postoperative AF after noncardiothoracic surgery; they suggest that it might be different from AF after cardiothoracic surgery in its pathogenesis, natural course and required management. To date, there have been no randomized controlled trials on new onset AF complicating noncardiothoracic surgery. Therefore, larger trials are needed to provide evidence based safe and effective strategies for the management of new onset AF in patients undergoing noncardiothoracic surgery.

C-Reactive Protein Levels and Atrial Fibrillation After Cardiac Surgery in Women

Rationale, considerations, and goals for atrial fibrillation centers of excellence: A Heart Rhythm Society perspective

Commentary: Atrial fibrillation: Surgeons can do more than operate

Statin medication has shown good results in the prevention of the postoperative atrial fibrillation (AF) after coronary artery bypass grafting (CABG).

Postoperative atrial fibrillation (AF) is the most common complication after coronary artery bypass graft (CABG) surgery, with an incidence of 20%-50%. The objective of this study was to investigate perioperative risk factors of postoperative sustained AF by the way of logistic regression analysis. Data for the last 98 patients who had undergone CABG surgery before January 2010 were retrospectively collected and analyzed. Postoperative sustained AF was detected in 34 (34.7%) patients. Mean arterial blood pressure, previous hypertension (HT), previous AF, previous chronic obstructive pulmonary disease, aortic cross-clamp time, cardiopulmonary bypass time, postoperative urea, postoperative creatinine, postoperative potassium, extubation time, chest tube drainage, units of transfused packed red blood cells (pRBC), and postoperative pneumonia were associated with higher occurrence of postoperative sustained AF according to the univariate analysis. Upon logistic regression analysis, pRBC transfusion, previous AF, and preoperative HT remained independent predictors for the development of postoperative sustained AF. On-pump versus off-pump CABG is not significantly associated with AF development so long as the operating time does not extend over a certain time period. pRBC transfusion was the single risk factor that is amenable to intervention at the time of operation. Unneeded transfusion of pRBCs must be prohibited. Also, serious precautions must be taken against postoperative pneumonia to avoid postoperative AF occurrence.

Background New-onset postoperative atrial fibrillation (POAF) is a common complication of cardiac surgery. However, data on the long-term risk of thromboembolism in patients who develop POAF after heart valve surgery are sparse. In addition, data on stroke prophylaxis in this setting are lacking. Objective To assess the long-term risk of thromboembolism in patients developing new-onset POAF following isolated left-sided heart valve surgery relative to patients with nonsurgical, nonvalvular atrial fibrillation (NVAF). Methods Using data from the Eastern Danish Heart Surgery Database and Danish nationwide registries, we identified patients who developed POAF following isolated left-sided heart valve surgery (i.e. biologic aortic/mitral valve replacement or aortic/mitral valve repair) from 2000 through 2015. These patients were matched with patients with nonsurgical NVAF in a 1:4 ratio by age, sex, heart failure, hypertension, diabetes, a history of thromboembolism, ischemic heart disease, and year of diagnosis. Long-term risk of thromboembolism was examined by the Aalen-Johansen estimator and cause-specific Cox regression models adjusted for comorbidities, concomitant pharmacotherapy, and oral anticoagulation therapy as a time-dependent covariate. Results A total of 1,539 patients undergoing isolated left-sided heart valve surgery were identified. Of these, 716 (46.5%) patients developed POAF after surgery. A total of 630 patients with POAF were matched with 2,520 patients with NVAF. In the matched study population, the median age was 71 years (25th-75th percentile 66–77 years) and 59.5% were men. Oral anticoagulation therapy was initiated within 30 days post-discharge in 62.7% and 51.4% of these patients, respectively. Compared with NVAF, POAF was not associated with a significantly different 5-year absolute risk of thromboembolism (10.7% [95% confidence interval [CI], 8.0%-13.9%] versus 8.9% [95% CI, 7.6%-10.2%] in the POAF and NVAF group, respectively) (Figure). In the adjusted analysis, the long-term risk of thromboembolism was similar in patients with POAF and NVAF (hazard ratio [HR] 1.01 [95% CI, 0.71–1.44]). Anticoagulation therapy during follow-up was associated with a lower risk of thromboembolic events in patients with POAF (HR 0.45 [95% CI, 0.18–0.99]) as well as NVAF (HR 0.58 [95% CI, 0.42–0.80]) compared with no anticoagulation therapy. Conclusions New-onset POAF following isolated left-sided heart valve surgery was associated with a similar long-term risk of thromboembolism compared with NVAF. Future studies addressing the role of oral anticoagulation therapy in POAF after heart valve surgery are warranted to examine the efficacy and safety as well as the timing and duration of anticoagulation therapy.

Minimally Invasive Esophagectomy In the Modern Era: Is Regional Anesthesia Still the Answer?

Morpho-Functional Features of the Radial Artery: Implications for Use as a Coronary Bypass Conduit