Samir rafla post cardiac surgery atrial fibrillation


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Causes, prevention and management of postoperative atrial fibrillation

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Samir rafla post cardiac surgery atrial fibrillation

  1. 1. Post Cardiac Surgery AtrialPost Cardiac Surgery AtrialFibrillationFibrillationProf. Samir Rafla, FACC, FESC.Alexandria Univ.smrafla@hotmail.comthe 19th Annual Conference of ESCTS 201311
  2. 2. 22Post-operative atrial fibrillation (POAF) is afrequent complication occurring in 30% to50% of patients after cardiac surgery.Post-operative AF tends to occur within 2to 4 days after the procedure, with a peakincidence on postoperative day 2. Seventypercent of patients develop this arrhythmiabefore the end of post-operative day 4 and94% before the end of post-operative day 6
  3. 3. Risk FactorsRisk FactorsThe most consistent predictor for theThe most consistent predictor for thedevelopment of POAF is advanceddevelopment of POAF is advanced ageage..Advanced age is associated with degenerativeAdvanced age is associated with degenerativeand inflammatory modifications in atrialand inflammatory modifications in atrialanatomy (dilation, fibrosis), which causeanatomy (dilation, fibrosis), which causealterations in atrial electrophysiologicalalterations in atrial electrophysiologicalproperties (shortness of effective refractoryproperties (shortness of effective refractoryperiod, dispersion of refractoriness andperiod, dispersion of refractoriness andconduction, abnormal automaticity,conduction, abnormal automaticity,33
  4. 4. 44Other risk factors for the development ofPOAF including a previous history of AF,male gender, decreased LV ejectionfraction, left atrial enlargement, valvularheart surgery, chronic obstructivepulmonary disease, chronic renal failure,diabetes mellitus, and rheumatic heartdisease .
  5. 5. More recently,More recently, obesityobesity has also beenhas also beenshown to be an independent predictor ofshown to be an independent predictor ofnew-onset AF. The metabolic syndromenew-onset AF. The metabolic syndromewas the only metabolic risk factor to bewas the only metabolic risk factor to beindependently associated with POAFindependently associated with POAFOther causes: peri-operativeOther causes: peri-operative heart failureheart failureand discontinuation of eitherand discontinuation of either beta blockerbeta blockeroror ACE inhibitorsACE inhibitors before or after surgery,before or after surgery,pericarditispericarditis and elevated postoperativeand elevated postoperativeadrenergic tone.adrenergic tone. 55
  6. 6. 66Mechanisms based on acute factorsInflammationThe similarity between the time courseof AF occurrence after cardiac surgeryand the activation of the complementsystem with the release of pro-inflammatory cytokines suggests aninflammatory component in themechanism triggering POAF.
  7. 7. Class IClass I""1.1. Unless contraindicated, treatment with  Unless contraindicated, treatment with an oral an oral beta blockerbeta blocker to prevent  to prevent postoperative postoperative AFAF is recommended for  is recommended for patients undergoing patients undergoing cardiac surgerycardiac surgery. . ((Level of Evidence: ALevel of Evidence: A))""""2.2. Administration of AV nodal blocking  Administration of AV nodal blocking agents is recommended to achieve rate agents is recommended to achieve rate control in patients who develop control in patients who develop postoperative postoperative AFAF. . ((Level of Evidence: BLevel of Evidence: B))""88
  8. 8. Class IIaClass IIa""1.1. Preoperative administration of  Preoperative administration of amiodaroneamiodarone reduces the incidence of  reduces the incidence of AFAF in patients undergoing  in patients undergoing cardiac surgerycardiac surgery and represents appropriate prophylactic  and represents appropriate prophylactic therapy for patients at high risk for therapy for patients at high risk for postoperative postoperative AFAF. . ((Level of Evidence: ALevel of Evidence: A))““99
  9. 9. ""2.2. It is reasonable to restore  It is reasonable to restore sinus rhythmsinus rhythm by  by pharmacological pharmacological cardioversioncardioversion with  with ibutilideibutilide or  or cardioversioncardioversion in patients who develop  in patients who develop postoperative postoperative AFAF as advised for nonsurgical  as advised for nonsurgical patients. patients. ((Level of Evidence: BLevel of Evidence: B))““""3.3. It is reasonable to administer  It is reasonable to administer antiarrhythmic medicationsantiarrhythmic medications in an attempt to  in an attempt to maintain maintain sinus rhythmsinus rhythm in pts with recurrent or  in pts with recurrent or refractory postoperative refractory postoperative AFAF, as for other pts , as for other pts who develop who develop AFAF. . ((Level of Evidence: BLevel of Evidence: B))""
  10. 10. Class IIaClass IIa-"-"4.4. It is reasonable to administer It is reasonable to administer antithrombotic medicationantithrombotic medication in pts who  in pts who develop postoperative develop postoperative AFAF, as for , as for nonsurgical pts. nonsurgical pts. Class IIbClass IIb- "- "1.1. Prophylactic administration of  Prophylactic administration of sotalolsotalol may be considered for patients at risk of  may be considered for patients at risk of developing developing AFAF following  following cardiac surgerycardiac surgery. . ((Level of Evidence: BLevel of Evidence: B))""1111
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  18. 18. 1919Drugs Used for Rate Control in POAFDrugs Used for Rate Control in POAF
  19. 19. Drugs Used for Rhythm Control in POAFDrugs Used for Rhythm Control in POAF2020
  20. 20. 2121
  21. 21. Post-Post-CABGCABG, there is an increased risk, there is an increased riskofof strokestroke; hence,; hence, heparinheparin oror oraloralanticoagulationanticoagulation may be appropriate if post-may be appropriate if post-opop AFAF persists for longer than 48 hours.persists for longer than 48 hours.Anticoagulation should be considered ifAnticoagulation should be considered ifpersistent POAF lasts >72 hours and at thepersistent POAF lasts >72 hours and at thepoint of hospital discharge.point of hospital discharge.Canadian Cardiovascular Society: Atrial Fibrillation Guidelines 2010:Canadian Cardiovascular Society: Atrial Fibrillation Guidelines 2010:Prevention and Treatment of Atrial Fibrillation Following CardiacPrevention and Treatment of Atrial Fibrillation Following CardiacSurgery .Surgery . Canadian Journal of Cardiology. Volume 27, Issue 1, January–Canadian Journal of Cardiology. Volume 27, Issue 1, January–FebruaryFebruary 20112011, Pages 91–97, Pages 91–972222
  22. 22. Colchicine Reduces Postoperative AtrialColchicine Reduces Postoperative AtrialFibrillationFibrillationConclusion—Conclusion—Colchicine seems safe andColchicine seems safe andefficacious in the reduction of POAF withefficacious in the reduction of POAF withthe potentiality of halving the complicationthe potentiality of halving the complicationand reducing the hospital stay.and reducing the hospital stay.CIRCULATIONCIRCULATION November 16, 2011November 16, 20112323
  23. 23. Randomized Trial of Atorvastatin forRandomized Trial of Atorvastatin forReduction of Postoperative AtrialReduction of Postoperative AtrialFibrillation in Patients Undergoing CardiacFibrillation in Patients Undergoing CardiacSurgerySurgeryCirculation.Circulation.2006; 114: 1455-14612006; 114: 1455-1461Conclusions—Conclusions— Treatment with atorvastatin 40Treatment with atorvastatin 40mg/d, initiated 7 days before surgery,mg/d, initiated 7 days before surgery,significantly reduces the incidence ofsignificantly reduces the incidence ofpostoperative AF after elective cardiac surgerypostoperative AF after elective cardiac surgerywith cardiopulmonary bypass and shortenswith cardiopulmonary bypass and shortenshospital stayhospital stay2424
  24. 24. Efficacy of posterior pericardiotomy inEfficacy of posterior pericardiotomy inpreventing atrial fibrillation after coronarypreventing atrial fibrillation after coronaryartery bypass surgery.artery bypass surgery.CONCLUSIONS:CONCLUSIONS: Posterior pericardiotomyPosterior pericardiotomyseems to significantly reduce the incidence ofseems to significantly reduce the incidence ofpostoperative atrial fibrillation andpostoperative atrial fibrillation andsupraventricular arrhythmias after coronarysupraventricular arrhythmias after coronaryartery bypass grafting. The marked reduction ofartery bypass grafting. The marked reduction ofpostoperative pericardial effusion after posteriorpostoperative pericardial effusion after posteriorpericardiotomy suggests that pericardial effusionpericardiotomy suggests that pericardial effusionis one of the main triggers involved in theis one of the main triggers involved in thedevelopment of atrial fibrillation after cardiacdevelopment of atrial fibrillation after J Thorac Cardiovasc Surg. 2010 May;139:1158-61.J Thorac Cardiovasc Surg. 2010 May;139:1158-61.
  25. 25. Post-operative Atrial FibrillationPost-operative Atrial Fibrillation