Causes, prevention and management of postoperative atrial fibrillation

1. Post Cardiac Surgery Atrial
Fibrillation
Prof. Samir Rafla, FACC, FESC.
Alexandria Univ.
smrafla@hotmail.com
the 19th Annual Conference of ESCTS 2013
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Post-operative atrial fibrillation (POAF) is a
frequent complication occurring in 30% to
50% of patients after cardiac surgery.
Post-operative AF tends to occur within 2
to 4 days after the procedure, with a peak
incidence on postoperative day 2. Seventy
percent of patients develop this arrhythmia
before the end of post-operative day 4 and
94% before the end of post-operative day 6

3. Risk Factors
The most consistent predictor for the
development of POAF is advanced age.
Advanced age is associated with degenerative
and inflammatory modifications in atrial
anatomy (dilation, fibrosis), which cause
alterations in atrial electrophysiological
properties (shortness of effective refractory
period, dispersion of refractoriness and
conduction, abnormal automaticity,
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Other risk factors for the development of
POAF including a previous history of AF,
male gender, decreased LV ejection
fraction, left atrial enlargement, valvular
heart surgery, chronic obstructive
pulmonary disease, chronic renal failure,
diabetes mellitus, and rheumatic heart
disease .

5. More recently, obesity has also been
shown to be an independent predictor of
new-onset AF. The metabolic syndrome
was the only metabolic risk factor to be
independently associated with POAF
Other causes: peri-operative heart
failure and discontinuation of either beta
blocker or ACE inhibitors before or after
surgery, pericarditis and elevated
postoperative adrenergic tone. 5

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Mechanisms based on acute factors
Inflammation
The similarity between the time course
of AF occurrence after cardiac surgery
and the activation of the complement
system with the release of pro-
inflammatory cytokines suggests an
inflammatory component in the
mechanism triggering POAF.

8. Class I
"1. Unless contraindicated, treatment with
an oral beta blocker to prevent
postoperative AF is recommended for
patients undergoing cardiac
surgery. (Level of Evidence: A)"
"2. Administration of AV nodal blocking
agents is recommended to achieve rate
control in patients who develop
postoperative AF. (Level of Evidence: B)"
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9. Class IIa
"1. Preoperative administration
of amiodarone reduces the incidence
of AF in patients undergoing cardiac
surgery and represents appropriate
prophylactic therapy for patients at high
risk for postoperative AF. (Level of
Evidence: A)“
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10. "2. It is reasonable to restore sinus rhythm by
pharmacological cardioversion with ibutilide or c
ardioversion in patients who develop
postoperative AF as advised for nonsurgical
patients. (Level of Evidence: B)“
"3. It is reasonable to administer antiarrhythmic
medications in an attempt to maintain sinus
rhythm in pts with recurrent or refractory
postoperative AF, as for other pts who
develop AF. (Level of Evidence: B)"

11. Class IIa
-"4. It is reasonable to
administer antithrombotic medication in
pts who develop postoperative AF, as for
nonsurgical pts.
Class IIb
- "1. Prophylactic administration
of sotalol may be considered for patients
at risk of developing AF following cardiac
surgery. (Level of Evidence: B)"
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Drugs Used for Rate Control in POAF
Drugs Used for Rate Control in POAF

20. Drugs Used for Rhythm Control in POAF
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22. Post-CABG, there is an increased risk of stroke;
hence, heparin or oral anticoagulation may be
appropriate if post-op AF persists for longer
than 48 hours.
Anticoagulation should be considered if
persistent POAF lasts >72 hours and at the
point of hospital discharge.
Canadian Cardiovascular Society: Atrial Fibrillation Guidelines 2010:
Prevention and Treatment of Atrial Fibrillation Following Cardiac
Surgery . Canadian Journal of Cardiology. Volume 27, Issue 1, January–
February 2011, Pages 91–97
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23. Colchicine Reduces Postoperative Atrial
Fibrillation
Conclusion—Colchicine seems safe and
efficacious in the reduction of POAF with
the potentiality of halving the complication
and reducing the hospital stay.
CIRCULATION November 16, 2011
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24. Randomized Trial of Atorvastatin for
Reduction of Postoperative Atrial Fibrillation
in Patients Undergoing Cardiac Surgery
Circulation.2006; 114: 1455-1461
Conclusions— Treatment with atorvastatin 40
mg/d, initiated 7 days before surgery,
significantly reduces the incidence of
postoperative AF after elective cardiac surgery
with cardiopulmonary bypass and shortens
hospital stay
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25. Efficacy of posterior pericardiotomy in
preventing atrial fibrillation after coronary
artery bypass surgery.
CONCLUSIONS: Posterior pericardiotomy
seems to significantly reduce the incidence of
postoperative atrial fibrillation and
supraventricular arrhythmias after coronary
artery bypass grafting. The marked reduction of
postoperative pericardial effusion after posterior
pericardiotomy suggests that pericardial effusion
is one of the main triggers involved in the
development of atrial fibrillation after cardiac
surgery. J Thorac Cardiovasc Surg. 2010 May;139:1158-61.

26. Post-operative Atrial Fibrillation