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Smith C, Lalu MM, Davis DR. Exploring Patient Viewpoints to Optimize Implementation of a Biological Therapy for Atrial Fibrillation Prevention. CJC Open 2024; 6:893-900. [PMID: 39026620 PMCID: PMC11252543 DOI: 10.1016/j.cjco.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/10/2024] [Indexed: 07/20/2024] Open
Abstract
Background Embracing patient viewpoints can enhance the translation of novel therapeutics to clinical settings. This study evaluated the acceptability of using extracellular vesicles (EVs) as a biological therapy for preventing postoperative atrial fibrillation (AF), through engagement with patients, providing insights into their attitudes and information needs. Methods Patients participated in prerecorded presentations, virtual focus groups, and surveys to assess their perspectives on EV therapy and determine the factors influencing their acceptance of the intervention. Results Participants with postoperative AF experienced prolonged intensive care unit and hospital stays, compared to those of patients with normal heart rhythm. Prior to the presentation, a number of participants were unfamiliar with postoperative AF and biological therapies. However, postpresentation and post-focus group activities resulted in enhanced understanding of the research, with high levels of comprehension reported by all participants. The level of acceptance of EV therapy tended to increase, with a majority expressing willingness to participate in clinical trials and accept the therapy. The focus groups identified and addressed common questions regarding the potential risks and side effects of EVs, their source, dosing, utility for patients with preexisting AF, and the risk of human immunodeficiency virus (HIV) contraction or allergic reactions. Conclusions The study highlights the importance of providing education, involving the patient's circle of care, and addressing patient concerns, to promote acceptance of therapies such as EV therapy for postoperative AF. Clinical Trial Registration NCT05032495.
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Affiliation(s)
- Chloé Smith
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Manoj M. Lalu
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
- Regenerative Medicine and Clinical Epidemiology Programs, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Darryl R. Davis
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Parent S, Amant JS, Remortel SV, Kahn S, Vaka R, Courtman D, Stewart DJ, Davis DR. Atrial Fibrosis and Inflammation in Postoperative Atrial Fibrillation: Comparative Effects of Amiodarone, Colchicine, or Exosomes. JACC Clin Electrophysiol 2024; 10:1037-1049. [PMID: 38639701 DOI: 10.1016/j.jacep.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/01/2024] [Accepted: 02/07/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Extracellular vesicles (EVs) isolated from human heart-derived cells have shown promise in suppressing inflammation and fibroblast proliferation. However, their precise benefits in atrial fibrillation (AF) prevention and the role of their antifibrotic/anti-inflammatory properties remain unclear. OBJECTIVES The purpose of this study was to conduct a head-to-head comparison of antiarrhythmic strategies to prevent postoperative AF using a rat model of sterile pericarditis. Specifically, we aimed to assess the efficacy of amiodarone (a classic antiarrhythmic drug), colchicine (an anti-inflammatory agent), and EVs derived from human heart-derived cells, which possess anti-inflammatory and antifibrotic properties, on AF induction, inflammation, and fibrosis progression. METHODS Heart-derived cells were cultured from human atrial appendages under serum-free xenogen-free conditions. Middle-aged Sprague Dawley rats were randomized into different groups, including sham operation, sterile pericarditis with amiodarone treatment, sterile pericarditis with colchicine treatment (2 dose levels), and sterile pericarditis with intra-atrial injection of EVs or vehicle. Invasive electrophysiological testing was performed 3 days after surgery before sacrifice. RESULTS Sterile pericarditis increased the likelihood of inducing AF. Colchicine and EVs exhibited anti-inflammatory effects, but only EV treatment significantly reduced AF probability, whereas colchicine showed a positive trend without statistical significance. EVs and high-dose colchicine reduced atrial fibrosis by 46% ± 2% and 26% ± 2%, respectively. Amiodarone prevented AF induction but had no effect on inflammation or fibrosis. CONCLUSIONS In this study, both amiodarone and EVs prevented AF, whereas treatment with colchicine was ineffective. The additional anti-inflammatory and antifibrotic effects of EVs suggest their potential as a comprehensive therapeutic approach for AF prevention, surpassing the effects of amiodarone or colchicine.
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Affiliation(s)
- Sandrine Parent
- University of Ottawa Heart Institute, Division of Cardiology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jennifer St Amant
- University of Ottawa Heart Institute, Division of Cardiology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sophie Van Remortel
- University of Ottawa Heart Institute, Division of Cardiology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Saad Kahn
- Ottawa Hospital Research Institute, Division of Regenerative Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ramana Vaka
- University of Ottawa Heart Institute, Division of Cardiology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - David Courtman
- Ottawa Hospital Research Institute, Division of Regenerative Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Duncan John Stewart
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Division of Regenerative Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Darryl Raymond Davis
- University of Ottawa Heart Institute, Division of Cardiology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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Maigrot JLA, Vargo PR, Kramer B, Rigelsky C, Ghobrial J, Zahka K, Najm H, Roselli EE. Multifocal disease progression and subsequent intervention in patients with actin alpha-2 variants: A single-center experience. J Thorac Cardiovasc Surg 2023:S0022-5223(23)01128-5. [PMID: 38065521 DOI: 10.1016/j.jtcvs.2023.11.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVES To describe patient characteristics and indications for surgical intervention, reoperation, and outcomes in patients with actin alpha-2 (ACTA2) variants. METHODS A single-center retrospective cohort study with prospective follow-up was performed for 38 patients with an ACTA2 variant. RESULTS From 1999 to 2020, 26 (70%) patients underwent surgery; 11 remain under surveillance (mean follow-up, 7.5 ± 5 years). Median age at index operation was 42 (range, 10-69) years, with 4 pediatric cases. Thoracic aortic aneurysm was present in 19 (73%) patients (mean adult max diameter, 5.2 ± 0.8 cm; pediatric z score, 10.7 ± 5.4). Aortic dissection was present in 13 (50%) patients, with 4 (15%) having type A dissection. Operations included replacement of the aortic root in 16 (17%), ascending aorta in 20 (77%), and aortic arch in 14 (54%) patients. Four (15%) patients had coronary artery disease, and 2 (7.7%) underwent concomitant coronary artery bypass grafting. There was no operative mortality, stroke, reoperation for bleeding, or dialysis-dependent renal failure; One (3.8%) patient developed acute on chronic kidney injury. Three patients (12%) required prolonged ventilation. Eleven (42%) patients underwent 26 reoperations, median time 45 (range, 4-147) months, including 5 open thoracoabdominal aneurysm repairs. CONCLUSIONS Patients with ACTA2 variants frequently develop aortic aneurysm and are at risk of aortic dissection and coronary artery disease. However, age at diagnosis and symptoms at presentation are highly variable. Multiple operations are often required for disease management, particularly after dissection. Close monitoring and timely intervention are important in mitigating disease progression and improving outcomes.
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Affiliation(s)
- Jean-Luc A Maigrot
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick R Vargo
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Benjamin Kramer
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Christina Rigelsky
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joanna Ghobrial
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kenneth Zahka
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Hani Najm
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Division of Pediatric and Congenital Heart Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Division of Pediatric and Congenital Heart Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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Statin and Postcardiac Surgery Atrial Fibrillation Prevention: A Systematic Review and Meta-Analysis. J Cardiovasc Pharmacol 2022; 80:180-186. [PMID: 35580320 DOI: 10.1097/fjc.0000000000001294] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 04/23/2022] [Indexed: 10/15/2022]
Abstract
ABSTRACT Postoperative atrial fibrillation (POAF) is a frequently reported postcardiac surgery complication leading to increased in-hospital and long-term mortality rates. Many randomized controlled trials (RCTs) have recently suggested using statins to protect against POAF. Therefore, we performed a systematic literature search and meta-analysis in electronic databases for eligible studies published between January 2006 and January 2022. The principal inclusion criteria were as follows: RCTs' study design, statin-naive patients, total study participants ≥50 units, and statin pretreatment started no more than 21 days before cardiac surgery. In the primary analysis, statin pretreatment reduced the incidence of POAF compared with placebo. Analyzing different molecules, atorvastatin was associated with lower incidence of POAF but rosuvastatin was not. We therefore performed a sensitivity analysis excluding RCTs affected by important risk of biases. Thus, studies whose participants were ≥199 were those eligible for the secondary analysis. No statistically significant difference between statin pretreatment and placebo (OR 0.87; 95% CI: 0.71-1.07, P = 0.18) as well as for atorvastatin (OR 0.88; 95% CI: 0.61-1.28; P = 0.48; I 2 = 84%) and rosuvastatin (OR 0.87; 95% CI: 0.68-1.12, P = 0.29) was observed. To conclude, statin pretreatment before cardiac surgery is not associated with a significant reduction in POAF occurrence.
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Karamnov S, O'Brien B, Muehlschlegel JD. A Wolf in Sheep's Skin? Postoperative Atrial Fibrillation After Cardiac Surgery and the Risk of Stroke and Mortality. J Cardiothorac Vasc Anesth 2021; 35:3565-3567. [PMID: 34518104 PMCID: PMC8819865 DOI: 10.1053/j.jvca.2021.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Sergey Karamnov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Benjamin O'Brien
- Departments of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Centre Berlin and Charité Universitätsmedizin Berlin
| | - Jochen D Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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Wang KKP, Liu W, Chew STH, Ti LK, Shen L. New-Onset Atrial Fibrillation After Cardiac Surgery is a Significant Risk Factor for Long-Term Stroke: An Eight-Year Prospective Cohort Study. J Cardiothorac Vasc Anesth 2021; 35:3559-3564. [PMID: 34330576 DOI: 10.1053/j.jvca.2021.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/19/2021] [Accepted: 07/05/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study sought to determine the incidence and significance of new-onset atrial fibrillation as a risk factor for long-term stroke and mortality after cardiac surgery. DESIGN A prospective cohort study. SETTING Two large tertiary public hospitals. PARTICIPANTS The study comprised 3008 patients who underwent coronary artery bypass grafting and/or valve surgery from 2008 to 2012. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS New-onset atrial fibrillation was analyzed as a risk factor for postoperative stroke using a multivariate logistic regression model after adjustment for potential confounders. A Cox regression model with time-dependent variables was used to analyze relationships between new-onset atrial fibrillation and postoperative survival. New-onset atrial fibrillation was detected in 573 (19.0%) patients. Stroke occurred in 234 (7.8%) patients during the mean postoperative follow-up period of six ± two years. The incidence of postoperative stroke in patients with new-onset atrial fibrillation (9.9%) and patients with both preoperative and postoperative atrial fibrillation (13.8%) was higher than in patients with no atrial fibrillation (6.8%) (p = 0.002). New-onset atrial fibrillation (odds ratio, 1.53; 95% confidence interval [CI], 1.08-2.18; p = 0.017) was identified as an independent risk factor for postoperative stroke. A total of 518 (17.2%) mortalities occurred within the mean postoperative follow-up period of eight ± two years. New-onset atrial fibrillation was associated with shorter survival (hazard ratio, 1.49; 95% CI, 1.22-1.81; p < 0.001) compared with patients with no atrial fibrillation. CONCLUSIONS New-onset atrial fibrillation is a significant risk factor for long-term stroke and mortality after cardiac surgery. Close monitoring and treatment of this condition may be necessary to reduce the risk of postoperative stroke and mortality.
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Affiliation(s)
- Kevin K P Wang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Weiling Liu
- Department of Anesthesia, National University Health System, Singapore
| | - Sophia T H Chew
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Duke-NUS Graduate Medical School, Singapore
| | - Lian Kah Ti
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Anesthesia, National University Health System, Singapore.
| | - Liang Shen
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Filardo G, Pollock BD, da Graca B, Sass DM, Phan TK, Montenegro DE, Ailawadi G, Thourani VH, Damiano RJ. Lower Survival After Coronary Artery Bypass in Patients Who Had Atrial Fibrillation Missed by Widely Used Definitions. Mayo Clin Proc Innov Qual Outcomes 2020; 4:630-637. [PMID: 33367207 PMCID: PMC7749274 DOI: 10.1016/j.mayocpiqo.2020.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To investigate the impact of limiting the definition of post-coronary artery bypass graft (CABG) atrial fibrillation (AF) to AF/flutter requiring treatment-as in the Society of Thoracic Surgeons' (STS) database- on the association with survival. Patients and Methods We assessed in-hospital incidence of post-CABG AF in 7110 consecutive isolated patients with CABG without preoperative AF at 4 hospitals (January 1, 2004 to December 31, 2010). Patients with ≥1 episode of post-CABG AF detected via continuous in-hospital electrocardiogram (ECG)/telemetry monitoring documented by physicians were assigned to the following: Group 1, identified as having post-CABG AF in STS data and Group 2, not identified as having post-CABG AF in STS data. Patients without documented post-CABG AF constituted Group 3. Survival was compared via a Cox model, adjusted for STS risk of mortality and accounting for site differences. Results Over 7 years' follow-up, 16.0% (295 of 1841) of Group 1, 18.7% (79 of 422) of Group 2, and 7.9% (382 of 4847) of Group 3 died. Group 2 had a significantly greater adjusted risk of death than both Group 1 (hazard ratio [HR]: 1.16; 95% confidence interval [CI], 1.02 to 1.33) and Group 3 (HR: 1.94; 95% CI, 1.69 to 2.22). Conclusions The statistically significant 16% higher risk of death for patients with AF post-CABG missed vs captured in STS data suggests treatment and postdischarge management should be investigated for differences. The historical misclassification of "missed" patients as experiencing no AF in the STS data weakens the ability to observe differences in risk between patients with and without post-CABG AF. Therefore, STS data should not be used for research examining post-CABG AF.
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Affiliation(s)
- Giovanni Filardo
- Department of Statistical Science, Southern Methodist University, Dallas, Texas.,Department of Epidemiology, Baylor Scott & White Health, Dallas, TX.,Robbins Institute for Health Policy & Leadership, Baylor University, Waco, TX.,The Heart Hospital Baylor Plano, Plano, TX
| | | | - Briget da Graca
- Robbins Institute for Health Policy & Leadership, Baylor University, Waco, TX.,Baylor Scott & White Research Institute, Dallas, TX
| | - Danielle M Sass
- Department of Epidemiology, Baylor Scott & White Health, Dallas, TX
| | - Teresa K Phan
- Department of Epidemiology, Baylor Scott & White Health, Dallas, TX
| | | | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA
| | - Vinod H Thourani
- Department of Cardiac Surgery, MedStar Heart and Vascular Institute and Georgetown University, Washington, DC
| | - Ralph J Damiano
- Department of Cardiac Surgery, Washington University School of Medicine and Barnes-Jewish Hospital, St Louis, MO
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Ronsoni RDM, Souza AZM, Leiria TLL, Lima GGD. Update on Management of Postoperative Atrial Fibrillation After Cardiac Surgery. Braz J Cardiovasc Surg 2020; 35:206-210. [PMID: 32369302 PMCID: PMC7199981 DOI: 10.21470/1678-9741-2019-0164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Postoperative atrial fibrillation (POAF) after cardiac surgery remarkably remains the most prevalent event in perioperative cardiac surgery, having great clinical and economic implications. The purpose of this study is to present recommendations based on international evidence and adapted to our clinical practice for the perioperative management of POAF. This update is based on the latest current literature derived from articles and guidelines regarding atrial fibrillation.
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Affiliation(s)
- Rafael de March Ronsoni
- Universidade da Região de Joinville SC Brazil Universidade da Região de Joinville, SC, Brazil.,Instituto de Cardiologia do Rio Grande do Sul Porto Alegre RS Brazil Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - Tiago Luiz Luz Leiria
- Instituto de Cardiologia do Rio Grande do Sul Porto Alegre RS Brazil Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Gustavo Glotz de Lima
- Instituto de Cardiologia do Rio Grande do Sul Porto Alegre RS Brazil Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Ruan Y, Robinson NB, Naik A, Silva M, Hameed I, Rahouma M, Oakley C, Di Franco A, Zamvar V, Girardi LN, Gaudino M. Effect of atrial pacing on post-operative atrial fibrillation following coronary artery bypass grafting: Pairwise and network meta-analyses. Int J Cardiol 2020; 302:103-107. [DOI: 10.1016/j.ijcard.2019.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/28/2019] [Accepted: 12/04/2019] [Indexed: 12/31/2022]
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Hsieh TH, Chen LW. Cardiopulmonary bypass not induces dysrhythmia in elderly coronary artery bypass grafting patients. Chirurgia (Bucur) 2019. [DOI: 10.23736/s0394-9508.18.04799-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Filardo G, Pollock BD, da Graca B, Phan TK, Sass DM, Ailawadi G, Thourani V, Damiano R. Underestimation of the incidence of new-onset post-coronary artery bypass grafting atrial fibrillation and its impact on 30-day mortality. J Thorac Cardiovasc Surg 2017; 154:1260-1266. [PMID: 28697894 DOI: 10.1016/j.jtcvs.2017.05.104] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 05/15/2017] [Accepted: 05/24/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Inconsistent definitions of atrial fibrillation after coronary artery bypass grafting have caused uncertainty about its incidence and risk. We examined the extent to which limiting the definition to post-coronary artery bypass grafting atrial fibrillation events requiring treatment underestimates its incidence and impact on 30-day mortality. METHODS We assessed in-hospital atrial fibrillation and 30-day mortality in 9268 consecutive patients without preoperative atrial fibrillation who underwent isolated coronary artery bypass grafting at 5 US hospitals (2004-2010). Patients who experienced 1 or more episode of post-coronary artery bypass grafting atrial fibrillation detected via continuous in-hospital electrocardiogram/telemetry monitoring were divided into those for whom Society of Thoracic Surgeons data (applying the definition "atrial fibrillation/flutter requiring treatment") also indicated atrial fibrillation versus those for whom it did not. Risk-adjusted 30-day mortality was compared between these 2 groups and with patients without post-coronary artery bypass grafting atrial fibrillation. RESULTS Risk-adjusted incidence of post-coronary artery bypass grafting atrial fibrillation incidence was 33.4% (27.0% recorded in Society of Thoracic Surgeons data, 6.4% missed). Patients with post-coronary artery bypass grafting atrial fibrillation missed by Society of Thoracic Surgeons data had a significantly greater risk of 30-day mortality (odds ratio, 2.08, 95% confidence interval, 1.17-3.69) than those captured. By applying the significant underestimation of post-coronary artery bypass grafting atrial fibrillation incidence we observed (odds ratio [Society of Thoracic Surgeons vs missed], 0.78; 95% confidence interval, 0.72-0.83) to the approximately 150,000 patients undergoing isolated coronary artery bypass grafting in the United States each year estimates this increased risk of mortality is carried by 9600 patients (95% confidence interval, 9420-9780) annually. CONCLUSIONS Defining post-coronary artery bypass grafting atrial fibrillation as episodes requiring treatment significantly underestimates incidence and misses patients at a significantly increased risk for mortality. Further research is needed to determine whether this increased risk carries over into long-term outcomes and whether it is mediated by differences in treatment and management.
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Affiliation(s)
- Giovanni Filardo
- Office of the Chief Quality Officer, Baylor Scott & White Health, Dallas, Tex; The Heart Hospital Baylor Plano, Plano, Tex.
| | - Benjamin D Pollock
- Office of the Chief Quality Officer, Baylor Scott & White Health, Dallas, Tex
| | - Briget da Graca
- Office of the Chief Quality Officer, Baylor Scott & White Health, Dallas, Tex
| | - Teresa K Phan
- Office of the Chief Quality Officer, Baylor Scott & White Health, Dallas, Tex
| | - Danielle M Sass
- Office of the Chief Quality Officer, Baylor Scott & White Health, Dallas, Tex
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - Vinod Thourani
- Division of Cardiothoracic surgery, Emory University, Atlanta, Ga
| | - Ralph Damiano
- Department of Cardiac Surgery, Washington University School of Medicine and Barnes-Jewish Hospital, St Louis, Mo
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Khan J, Khan N, Loisa E, Sutinen J, Laurikka J. Increasing Occurrence of Postoperative Atrial Fibrillation in Contemporary Cardiac Surgery. J Cardiothorac Vasc Anesth 2016; 30:1302-7. [DOI: 10.1053/j.jvca.2016.02.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Indexed: 11/11/2022]
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Abstract
Atrial fibrillation is the most commonly encountered arrhythmia after cardiac surgery. Although usually self-limiting, it represents an important predictor of increased patient morbidity, mortality, and health care costs. Numerous studies have attempted to determine the underlying mechanisms of postoperative atrial fibrillation (POAF) with varied success. A multifactorial pathophysiology is hypothesized, with inflammation and postoperative β-adrenergic activation recognized as important contributing factors. The management of POAF is complicated by a paucity of data relating to the outcomes of different therapeutic interventions in this population. This article reviews the literature on epidemiology, mechanisms, and risk factors of POAF, with a subsequent focus on the therapeutic interventions and guidelines regarding management.
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New-onset atrial fibrillation predicts long-term newly developed atrial fibrillation after coronary artery bypass graft. Am Heart J 2014; 167:593-600.e1. [PMID: 24655710 DOI: 10.1016/j.ahj.2013.12.010] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 12/08/2013] [Indexed: 01/01/2023]
Abstract
BACKGROUND New-onset postoperative atrial fibrillation (POAF) is associated with poor short- and long-term outcomes after isolated coronary artery bypass graft (CABG). This study evaluated whether new-onset POAF is independently associated with long-term (>1 year) atrial fibrillation (AF) and mortality. METHODS Among 1,171 consecutive patients who had undergone CABG, AF and mortality were compared between patients with POAF (POAF group, n = 244) and those without POAF (no-POAF group, n = 927) after propensity score matching. RESULTS During the follow-up period of 41 ± 23 months (range 0-87 months), the POAF group had a higher incidence of total (20/927 [2.2%] vs 46/244 [18.9%], P < .001) and long-term AF recurrence (13/927 [1.4%] vs 25/244 [10.2%], P < .001). Even after propensity score matching, the POAF group still showed a higher incidence of total (7/244 [2.9%] vs 46/224 [18.9%], P < .001) and long-term AF recurrence (4/244 [1.6%] vs 25/224 [10.2%], P < .001). In addition, the POAF group had a lower cumulative survival free of long-term AF than the no-POAF group (P < .001). In competing risk regression, POAF was an independent predictor of long-term newly developed AF (hazard ratio 4.99, 95% CI 1.68-14.84, P = .004). Cumulative survival free of death was worse in patients with POAF (P = .01). CONCLUSIONS New-onset POAF was shown to be a predictor of long-term newly developed AF in CABG patients. The results of this study suggest that patients who develop POAF should undergo strict surveillance and routine screening for AF during follow-up after surgery.
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Postoperative arrhythmias after cardiac surgery: incidence, risk factors, and therapeutic management. Cardiol Res Pract 2014; 2014:615987. [PMID: 24511410 PMCID: PMC3912619 DOI: 10.1155/2014/615987] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 10/16/2013] [Indexed: 01/16/2023] Open
Abstract
Arrhythmias are a known complication after cardiac surgery and represent a major cause of morbidity, increased length of hospital stay, and economic costs. However, little is known about incidence, risk factors, and treatment of early postoperative arrhythmias. Both tachyarrhythmias and bradyarrhythmias can present in the postoperative period. In this setting, atrial fibrillation is the most common heart rhythm disorder. Postoperative atrial fibrillation is often self-limiting, but it may require anticoagulation therapy and either a rate or rhythm control strategy. However, ventricular arrhythmias and conduction disturbances can also occur. Sustained ventricular arrhythmias in the recovery period after cardiac surgery may warrant acute treatment and long-term preventive strategy in the absence of reversible causes. Transient bradyarrhythmias may be managed with temporary pacing wires placed at surgery, but significant and persistent atrioventricular block or sinus node dysfunction can occur with the need for permanent pacing. We provide a complete and updated review about mechanisms, risk factors, and treatment strategies for the main postoperative arrhythmias.
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Sabzi F, Zokaei AH, Moloudi AR. Predictors of atrial fibrillation following coronary artery bypass grafting. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2011; 5:67-75. [PMID: 21836815 PMCID: PMC3153115 DOI: 10.4137/cmc.s7170] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background: Atrial fibrillation (AF) is a frequent and serious complication of coronary artery bypass graft (CABG) surgery. Methods: We undertook a retrospective review of the records of patients undergoing CABG at Imam Ali Hospital between February 1, 2003 and February 1, 2006. The patients were divided in two groups, ie, Group A (AF) and Group B (no AF). The association between the occurrence of AF following CABG and other variables was compared with respect to continuous or categorical variables by t-test and χ2-test. Results: Multivariate logistic regression analysis of potentially predictive factors in univariate analysis showed that opium use, type of operation, and crossclamp time were predictors of AF following CABG. Conclusion: This study identifies some new predictors of postoperative AF, control of which could lead to a lower incidence of AF and reduced morbidity, mortality, and resource utilization for patients undergoing cardiac surgery.
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Affiliation(s)
- Feridoun Sabzi
- Imam Ali Heart Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Enríquez F, Jiménez A. Taquiarritmias postoperatorias en la cirugía cardíaca del adulto. Profilaxis. CIRUGIA CARDIOVASCULAR 2010. [DOI: 10.1016/s1134-0096(10)70100-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Price J, Tee R, Lam BK, Hendry P, Green MS, Rubens FD. Current Use of Prophylactic Strategies for Postoperative Atrial Fibrillation: A Survey of Canadian Cardiac Surgeons. Ann Thorac Surg 2009; 88:106-10. [DOI: 10.1016/j.athoracsur.2009.03.059] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2008] [Revised: 03/18/2009] [Accepted: 03/23/2009] [Indexed: 10/20/2022]
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Sleeswijk ME, Van Noord T, Tulleken JE, Ligtenberg JJM, Girbes ARJ, Zijlstra JG. Clinical review: treatment of new-onset atrial fibrillation in medical intensive care patients--a clinical framework. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:233. [PMID: 18036267 PMCID: PMC2246197 DOI: 10.1186/cc6136] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Atrial fibrillation occurs frequently in medical intensive care unit patients. Most intensivists tend to treat this rhythm disorder because they believe it is detrimental. Whether atrial fibrillation contributes to morbidity and/or mortality and whether atrial fibrillation is an epiphenomenon of severe disease, however, are not clear. As a consequence, it is unknown whether treatment of the arrhythmia affects the outcome. Furthermore, if treatment is deemed necessary, it is not known what the best treatment is. We developed a treatment protocol by searching for the best evidence. Because studies in medical intensive care unit patients are scarce, the evidence comes mainly from extrapolation of data derived from other patient groups. We propose a treatment strategy with magnesium infusion followed by amiodarone in case of failure. Although this strategy seems to be effective in both rhythm control and rate control, the mortality remained high. A randomised controlled trial in medical intensive care unit patients with placebo treatment in the control arm is therefore still defendable.
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Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia seen after cardiac surgery. It is associated with prolongation of hospital stay, postoperative complications, stroke, mortality, and increased hospital cost. Several prevention strategies have been proven effective in reducing postoperative AF; in addition, active prevention of postoperative AF is associated with a decrease in the length of hospital stay and a reduction trend in hospital costs. In patients with postoperative AF, restoration and maintenance of sinus rhythm and rate control are adequate treatment alternatives in the majority of cases. In severely symptomatic or hemodynamically compromised patients urgent cardioversion is needed. Adequate oral anticoagulation may be indicated for a limited period of time.
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Affiliation(s)
- Orhan Onalan
- Arrhythmia Services, Division of Cardiology, Sunnybrook and Women's College Health Sciences Centre, 2075 Bayview Avenue, A253, Toronto, ON M4N 3M5, Canada
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Izhar U, Ad N, Rudis E, Milgalter E, Korach A, Viola N, Levi E, Asraff G, Merin G, Elami A. When should we discontinue antiarrhythmic therapy for atrial fibrillation after coronary artery bypass grafting? A prospective randomized study. J Thorac Cardiovasc Surg 2005; 129:401-6. [DOI: 10.1016/j.jtcvs.2004.06.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Amar D, Shi W, Hogue CW, Zhang H, Passman RS, Thomas B, Bach PB, Damiano R, Thaler HT. Clinical prediction rule for atrial fibrillation after coronary artery bypass grafting. J Am Coll Cardiol 2004; 44:1248-53. [PMID: 15364327 DOI: 10.1016/j.jacc.2004.05.078] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2004] [Revised: 05/04/2004] [Accepted: 05/11/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This study was designed to devise and validate a practical prediction rule for atrial fibrillation/atrial flutter (AF) after coronary artery bypass grafting (CABG) using easily available clinical and standard electrocardiographic (ECG) criteria. BACKGROUND Reported prediction rules for postoperative AF have suffered from inconsistent results and controversy surrounding the added predictive value of a prolonged P-wave duration. METHODS In 1,851 consecutive patients undergoing CABG with cardiopulmonary bypass, preoperative clinical characteristics and standard 12-lead ECG data were examined. Patients were continuously monitored for the occurrence of sustained postoperative AF while hospitalized. Multiple logistic regression was used to determine significant predictors of AF and to develop a prediction rule that was evaluated through jackknifing. RESULTS Atrial fibrillation occurred in 508 of 1,553 patients (33%). Multivariate analysis showed that greater age (odds ratio [OR] 1.1 per year [95% confidence intervals (CI) 1.0 to 1.1], p < 0.0001), prior history of AF (OR 3.7 [95% CI 2.3 to 6.0], p < 0.0001), P-wave duration >110 ms (OR 1.3 [95% CI 1.1 to 1.7], p = 0.02), and postoperative low cardiac output (OR 3.0 [95% CI 1.7 to 5.2], p = 0.0001) were independently associated with AF risk. Using the prediction rule we defined three risk categories for AF: <60 points, 61 of 446 (14%); 60 to 79 points, 330 of 908 (36%); and >or=80 points, 117 of 199 (59%). The area under the receiver-operator characteristic curve for the model was 0.69. CONCLUSIONS These data show that post-CABG AF can be predicted with moderate accuracy using easily available patient characteristics and may prove useful in prognostic and risk stratification of patients after CABG. The presence of intraatrial conduction delay on ECG contributed least to the prediction model.
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Affiliation(s)
- David Amar
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center and Weill Medical College of Cornell University, New York, New York 10021, USA.
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