Management of Postoperative Atrial Fibrillation Stephen D. Cassivi, MD MSc FRCSC FACS Professor of Surgery Vice Chair – Department of Surgery [email protected]

Management of Postoperative Atrial FibrillationStephen D. Cassivi, MD MSc FRCSC FACS

Professor of Surgery

Vice Chair – Department of Surgery

[email protected]

Financial Relationship / Conflict of Interest Disclosure

Statement

I have NO financial relationships or

potential conflicts of interest to report

Take Home Messages

Take Home Messages

1. Frequent

2. Mostly Self-Limited

3. Difficult to Prevent

4. Hemodynamic stability defines Treatment Goals

• Unstable Patient Restore HD stability

• Stable Patient Rate Control

5. Anticoagulation – based on individual patient risk

Key References: JTCVS 2014;148:772-791.JACS 2013;219:831-841.

Postoperative Atrial Fibrillation - POAF

Most common sustained arrhythmia after pulmonary and esophageal surgery.

Postoperative Atrial Fibrillation – POAFImpact

• Major, potentially preventable adverse outcome

ICU length of stay

ICU readmission

Hospital length of stay

Morbidity – stroke, bleeding

Mortality (RR 1.7-3.4)

Resource utilization

Postoperative Atrial Fibrillation – POAFTimecourse

• POAF occurrence peaks on POD 2-4

• 90-98% of new onset POAF resolves within 4-6 weeks

Ann Thorac Surg 2011;92:421–7

Postoperative Atrial Fibrillation – POAFMechanisms

Requires BOTH:

• “Triggers”• Rapidly firing ectopic focus

• Reentrant circuit of short cycle length

• Multiple reentrant ‘wavelets’

• “Vulnerable Substrate”• Sympathetic or parasympathetic

stimulation

• Atrial dilation or acute atrial stretch

• Pericarditis

• Fibrosis

• Conduction abnormalities

• Inflammation or oxidative stress

Postoperative Atrial Fibrillation – POAFIncidence

• Incidence varies• Incidence Intensity of surgical procedure



Low Riskof POAF

Bronchoscopy

VATS biopsy

Laparoscopic Nissen



Low Riskof POAF

Bronchoscopy

VATS biopsy

Laparoscopic Nissen

VATS Lobectomy

Open Lobectomy

Thymectomy

Intermediate Riskof POAF



Low Riskof POAF

High Riskof POAF

Bronchoscopy

VATS biopsy

Laparoscopic Nissen

Extrapleural Pneumonectomy

Esophagectomy

VATS Lobectomy

Open Lobectomy

Thymectomy

Intermediate Riskof POAF





New onset atrial fibrillation with rapid ventricular response

44/606 (7.3%)

Postoperative Atrial Fibrillation – POAFIncidence – Patient Factors

• Modifiable Factors

• Hypertension

• Valvular Heart

Disease

• Obesity

• Obstr. Sleep Apnea

• Hyperthyroidism

• Smoking

• Nonmodifiable Factors

• Age

• Race

• Male

• History of arrhythmias

Postoperative Atrial Fibrillation – POAFGuidelines

JTCVS 2014;148:772-791.

Thromboembolic Stroke

CHA2DS2-VASc

Chest 2010;137:263-72.

Postoperative Atrial Fibrillation – POAFAATS Guidelines

Monitoring / Telemetry• No monitoring necessary – if:

• Low Risk procedure• No prior history of arrhythmias/HF/CVA• CHA2DS2-VASc < 2

• 48-72 hours of Monitoring / Telemetry – if:• Intermed or High Risk procedure• CHA2DS2-VASc ≥ 2

• Hx of pre-existing or periodic recurrent AF


Prevention

• Avoidance of β-blockade withdrawal

• Correction of abnormal serum Mg++ levels


Treatment

• Depends on Hemodynamic Stability

UNSTABLE:Restore Sinus Rhythm

STABLE:Rate Control


Treatment• For ALL patients:

• Reduce or stop catecholaminergic inotropic agents

(if hemodynamics allow)

• Optimize fluid balance

• Correct electrolyte abnormalities

• Treat/correct possible triggering factors

• Bleeding, PE, Pneumothorax, Ischemia/MI, Infection/Sepsis


Treatment - UNSTABLE• Primary Goal = Restore Sinus Rhythm

1. Cardioversion

2. If Cardioversion unsuccessful or unstable POAF recurs:• Initiate IV Esmolol / Digoxin / Diltiazem /

Amiodarone• Prepare to Cardiovert again


Treatment - STABLE• Primary Goal = Rate Control

1. Β-blocker (esmolol/metoprolol) or Ca++ channel blocker (diltiazem, verapamil) to achieve HR ≤ 110 bpm

2. For pts with HF, LV dysfnx, or unresponsive to above tx Amiodarone

Caveat: WPW syndrome


Treatment• Cardiology consultation if:

• Recurrent or refractory POAF

• Persistent hemodynamic instability

• CHAD-VASc score high

• Require second-line anti-arrhythmic agent

• Develop acute renal injury/failure


Follow-up

• Cardiology follow-up if:

• EF ≤ 45%

• Dx of Systolic HF or Cardiomyopathy

• Started NEW rhythm control agent

• POAF last > 6 weeks


Anticoagulation Treatment

• During first 48h from onset

• Anticoagulation decision based on TE risk

(CHADS-VASc)

• Stable POAF >48 hours duration

• Anticoagulation is recommended

Anticoagulation


Results

January 1994 – December 2009

527 232

759 Patients

Median Age – 71 years (Range 31 – 92)

ResultsStrokes

8 (1.1%) patients developed a stroke

• Not anticoagulated - 3 (0.6%) pts.• Anticoagulated - 5 (2.2%) pts.

(p=0.057)

ResultsBleeding

49 (6.5%) patients developed a bleeding complication

Not anticoagulated - 27 (5.1%)* pts.

Anticoagulated - 22 (9.6%)* pts.

*statistically different p=0.009

Conclusions

• Anticoagulation did not lower the risk of stroke or TIA

• Anticoagulation was associated with an increase in postoperative bleeding

• Routine anticoagulation for POAF should be avoided

Postoperative Atrial Fibrillation – POAFGuidelines

Anticoagulation Treatment

• Anticoagulation decision based on TE risk

(CHADS-VASc)

• Both within and beyond 48 hours

JACS 2013;219:831-841.

JACS 2013;219:831-841.

JACS 2013;219:831-841.

JACS 2013;219:831-841.

JACS 2013;219:831-841.

JACS 2013;219:831-841.

JACS 2013;219:831-841.

Take Home Messages

1. Frequent

2. Mostly Self-Limited

3. Difficult to Prevent

4. Hemodynamic stability defines Treatment Goals

• Unstable Patient Restore HD stability

• Stable Patient Rate Control

5. Anticoagulation – based on individual patient risk

Key References: JTCVS 2014;148:772-791.JACS 2013;219:831-841.

[email protected]

Documents

Management of Postoperative Atrial Fibrillation Stephen D. Cassivi, MD MSc FRCSC FACS Professor of Surgery Vice Chair – Department of Surgery [email protected]