The clinical course of new-onset atrial fibrillation after elective aortic operations

Atrial fibrillation in vascular surgery: a systematic review and meta-analysis on prevalence, incidence and outcome implications

AIMS

To know the prevalence of atrial fibrillation (AF), as well as the incidence of postoperative AF (POAF) in vascular surgery for arterial diseases and its outcome implications.

METHODS

We performed a systematic review and meta-analysis following the PRISMA statement.

RESULTS

After the selection process, we analyzed 44 records (30 for the prevalence of AF history and 14 for the incidence of POAF).The prevalence of history of AF was 11.5% [95% confidence interval (CI) 1-13.3] with high heterogeneity (I2 = 100%). Prevalence was higher in the case of endovascular procedures. History of AF was associated with a worse outcome in terms of in-hospital death [odds ratio (OR) 3.29; 95% CI 2.66-4.06; P < 0.0001; I2 94%] or stroke (OR 1.61; 95% CI 1.39-1.86; P < 0.0001; I2 91%).The pooled incidence of POAF was 3.6% (95% CI 2-6.4) with high heterogeneity (I2 = 100%). POAF risk was associated with older age (mean difference 4.67 years, 95% CI 2.38-6.96; P = 0.00007). The risk of POAF was lower in patients treated with endovascular procedures as compared with an open surgical procedure (OR 0.35; 95% CI 0.13-0.91; P = 0.03; I2 = 61%).

CONCLUSIONS

In the setting of vascular surgery for arterial diseases a history of AF is found overall in 11.5% of patients, more frequently in the case of endovascular procedures, and is associated with worse outcomes in terms of short-term mortality and stroke.The incidence of POAF is overall 3.6%, and is lower in patients treated with an endovascular procedure as compared with open surgery procedures. The need for oral anticoagulants for preventing AF-related stroke should be evaluated with randomized clinical trials.

Major Adverse Cardiac Events after Elective Infrarenal Endovascular Aortic Aneurysm Repair

OBJECTIVE

There is a significant cardiac morbidity and mortality after endovascular aneurysm repair (EVAR). However, information about long-term risk of cardiac events after EVAR and potential predictors is lacking. Therefore, the aim of this study was to determine incidence and predictors of major adverse cardiac events (MACE) at one- and five-years after elective EVAR for infrarenal abdominal aortic aneurysms.

METHODS

Baseline, perioperative and postoperative information of 320 patients was evaluated. The primary outcome was the incidence of MACE after EVAR, which was defined as acute coronary syndrome, unstable angina pectoris, de novo atrial fibrillation, hospitalization for heart failure, mitral valve insufficiency, revascularization (including PCI and CABG), as well as cardiovascular and non-cardiovascular death. Kaplan Meier analysis was performed to determine incidences of MACE, MACE excluding non-cardiovascular death and cardiac events by excluding non-cardiovascular and vascular death from MACE. Predictors of MACE were identified using univariate and multivariate binary regression analysis.

RESULTS

Through one- and five-years follow-up after EVAR, freedom from MACE was 89.4% (standard error (SE) 0.018) and 59.8% (SE 0.033), freedom from MACE excluding non-cardiovascular death was 94.7% (SE 0.013) and 77.5% (SE 0.030) and freedom from cardiac events was 96.0% (SE 0.011) and 79.1% (SE 0.030), respectively. Predictors for MACE within one-year were American Society of Anaesthesiologists (ASA) score 3 or 4 (OR, 3.17; 95% CI, 1.52-6.59) and larger abdominal aortic diameter (OR, 1.04; 95% CI, 1.01-1.08). History of atrial fibrillation (OR, 0.14; 95% CI, 0.03-0.60) was a negative predictor factor. Predictors for MACE through five-years were history of heart failure (OR, 4.10; 95% CI 1.36-12.32) and valvular heart disease (OR, 2.31; 95% CI, 0.97-5.51), ASA score 3 or 4 (OR, 1.66; 95% CI, 0.96-2.88) and older age (OR, 1.04; 95% CI, 1.01-1.08).

CONCLUSION

MACE is a common complication during the first five-years after elective EVAR. Cardiac diseases at baseline are strong predictors for long-term MACE and potentially helpful in optimizing future post-operative long-term follow-up.

New-Onset Postoperative Atrial Fibrillation After Total Arch Repair Is Associated With Increased In-Hospital Mortality

Background

It is well established that postoperative atrial fibrillation (POAF) is associated with adverse postoperative outcomes after major cardiac operations. The purpose of this study was to investigate the incidence of new‐onset POAF after successful total arch repair surgery and the association between POAF and in‐hospital mortality.

Methods and Results

All consecutive patients undergoing total arch repair from September 2012 to December 2019 in Fuwai hospital were enrolled (n=1280). Patients diagnosed with preoperative atrial fibrillation were excluded. POAF was diagnosed as the new‐onset atrial fibrillation or flutter for more than 5 minutes based on continuous electrocardiogram monitoring. A logistic regression model was used to determine predictors of in‐hospital mortality. Multivariable adjustment, inverse probability of treatment weighting, and propensity score matching were used to adjust for confounders. POAF was diagnosed in 32.3% (411/1271) of this cohort population. The occurrence of new‐onset POAF was associated with age (odds ratio [OR], 1.05; 95% CI, 1.04–1.06; P<0.001), male sex (OR, 0.72; 95% CI, 0.52–0.98; P=0.035), and surgery duration (OR, 1.2; 95% CI, 1.12–1.28; P<0.001). The in‐hospital mortality was significantly higher in patients with POAF than those without POAF (10.7% versus 2.4%, P<0.001). Inverse probability of treatment weighting and propensity score matching analyses confirmed the results. The increased in‐hospital mortality in POAF group still existed among subgroup analysis based on different age, sex, hypertension, smoking, and hypokalemia, combined with cardiac surgery, and deep hypothermic circulatory arrest.

Conclusions

More careful attention should be given to POAF after total arch repair surgery. The incidence of POAF after total arch repair surgery was 32.3% and associated with increased in‐hospital mortality. The elderly female patient who experienced longer operation duration was at highest risk for POAF.

Describing Clinically Significant Arrhythmias in Postoperative Vascular Surgery Patients

BACKGROUND

The American Heart Association guidelines instruct use of postoperative telemetry (POT) should be reserved for patients undergoing cardiac procedures and/or those with ischemic cardiac symptoms, but acknowledge that major vascular procedures deserve unique consideration. Telemetry remains a limited resource in many hospitals; however, it has been poorly defined which vascular patients have greatest need for POT. The purpose of this study is to define the rates of postoperative arrhythmias (POAs) after major vascular operations using the Society for Vascular Surgery Vascular Quality Initiative (VQI) registry, identify independent predictors of POA, and determine the effect of POA on mortality to guide the use of POT in vascular patients.

METHODS

A retrospective cohort study was performed using the following VQI modules: open abdominal aortic aneurysm repair (oAAA), complex endovascular aneurysm repair (EVAR) (thoracic endovascular aortic repair [TEVAR]/c-EVAR), EVAR, suprainguinal bypass (SIB), and infrainguinal bypass (IIB). POA was defined in the VQI as a new rhythm disturbance requiring treatment with medication or cardioversion. The incidence of POA, preoperative risk factors, and demographics were determined for each procedure.

RESULTS

A total of 121,652 procedures were identified with an overall POA event rate of 5.1% (n = 6,265). Procedure-specific event rates for POA among VQI registries are as follows: oAAA 14.4%, TEVAR/c-EVAR 8.5%, EVAR 2.7%, SIB 6.2%, and IIB 3.8%. Across all procedure types, POA was associated with emergent operations and increased procedure time. Procedure-specific multivariable regression revealed additional independent preoperative intraoperative factors associated with POA that were unique with each procedure. Across all procedural groups, the presence of POA was associated with increased rates of clinical myocardial infarction and decreased survival on Kaplan-Meier analysis.

CONCLUSIONS

Rates of POA in patients undergoing vascular procedures appear higher than previously reported, and POA is associated with decreased survival. Our study elucidated patient- and procedure-specific predictor factors associated with POA that can be used to inform the use of POT.

Transient postoperative atrial fibrillation after abdominal aortic aneurysm repair increases mortality risk

OBJECTIVE

The purpose of this study was to determine whether new-onset transient postoperative atrial fibrillation (TPAF) affects mortality rates after abdominal aortic aneurysm (AAA) repair and to identify predictors for the development of TPAF.

METHODS

Patients who underwent open aortic repair or endovascular aortic repair for a principal diagnosis AAA were retrospectively identified using the Healthcare Cost and Utilization Project-State Inpatient Database (Florida) for 2007 to 2011 and monitored longitudinally for 1 year. Inpatient and 1-year mortality rates were compared between those with and without TPAF. TPAF was defined as new-onset atrial fibrillation that developed in the postoperative period and subsequently resolved in patients without a history of atrial fibrillation. Cox proportional hazards models, adjusted for age, gender, comorbidities, rupture status, and repair method, were used to assess 1-year survival. Predictive models were built with preoperative patient factors using Chi-squared Automatic Interaction Detector decision trees and externally validated on patients from California.

RESULTS

A 3.7% incidence of TPAF was identified among 15,148 patients who underwent AAA repair. The overall mortality rate was 4.3%. The inpatient mortality rate was 12.3% in patients with TPAF vs 4.0% in those without TPAF. In the ruptured setting, the difference in mortality was similar between groups (33.7% vs 39.9%, P = .3). After controlling for age, gender, comorbid disease severity, urgency (ruptured vs nonruptured), and repair method, TPAF was associated with increased 1-year postoperative mortality (hazard ratio, 1.48; P < .001) and postdischarge mortality (hazard ratio, 1.56; P = .028). Chi-squared Automatic Interaction Detector-based models (C statistic = 0.70) were integrated into a Web-based application to predict an individual's probability of developing TPAF at the point of care.

CONCLUSIONS

The development of TPAF is associated with an increased risk of mortality in patients undergoing repair of nonruptured AAA. Predictive modeling can be used to identify those patients at highest risk for developing TPAF and guide interventions to improve outcomes.

The incidence of hypomagnesaemia following abdominal aortic aneurysm surgery

INTRODUCTION

Magnesium is important for cardiac function. Hypomagnesaemia is associated with a higher incidence of arrhythmias and poorer outcomes in cardiac surgery. No studies have investigated the incidence or impact of postoperative hypomagnesaemia after abdominal aortic aneurysm (AAA) surgery. We aim to assess the incidence of hypomagnesaemia after AAA repair in our population.

METHODS

Retrospective analysis was performed of patients who underwent elective AAA surgery at a single vascular centre. The last 110 patients undergoing open or endovascular AAA repair were identified. The hospital pathology system was used to identify the immediate postoperative serum magnesium levels as well as patient demographics and admission details. Hypomagnesaemia was defined as serum magnesium of <0.7 mmol/l.

RESULTS

A total of 211 patients were studied and there were 3 deaths. Of the patients included, 101 underwent open elective AAA repair and 110 underwent endovascular repair. In the elective open repair group, 73 patients (73%) were hypomagnesaemic. In the endovascular repair group, 35 (32%) had hypomagnesaemia. A t-test showed a statistically significant difference in hypomagnesaemia between the open and endovascular groups (p<0.001).

CONCLUSIONS

AAA surgery is associated with a high incidence of postoperative hypomagnesaemia, which is significantly greater among open repair patients. This is likely to have an effect on cardiac activity and lead to cardiac complications such as arrhythmias and poorer postoperative outcomes, especially in the open AAA repair subgroup. This stresses the importance of serum magnesium and cardiac monitoring in the postoperative phase. A prospective study is proposed to further investigate these findings, and their potential implications on perioperative morbidity and mortality.

Management of arrhythmias in the perioperative setting

Perioperative arrhythmias are a common complication of surgery, with incidence ranging from 4% to 20% for noncardiothoracic procedures, depending on the type of surgery performed. The immediate postoperative period is a dynamic time and is associated with many conditions conducive to the development of postoperative arrhythmias. The presence of postoperative atrial fibrillation is associated with increased morbidity, ICU stay, length of hospitalization, and hospital costs. The associated burdens are expected to rise in the future, given that the population undergoing cardiac surgery is getting older and sicker. Thousands of patients undergo major surgery each year and a major complication of these procedures is the occurrence of perioperative arrhythmia. It is imperative for clinicians to be up-to-date on current management of these arrhythmias.

Prognosis of transient new-onset atrial fibrillation during vascular surgery

BACKGROUND

Chronic atrial fibrillation (AF) in a non-surgical setting is associated with cardiovascular events. However, the prognosis of transient new-onset AF during vascular surgery is unknown.

OBJECTIVE

The purpose of this study is to investigate the prognosis of new-onset AF during vascular surgery using continuous electrocardiographic monitoring (continuous-ECG).

METHODS

In this study, 317 patients, all in sinus rhythm, scheduled for major vascular surgery were screened for cardiac risk factors. Continuous-ECG recordings for 72h and standard ECG on days 3, 7 and 30 were used to identify new-onset AF. Cardiac troponin T (cTnT) was measured routinely after surgery. Study endpoint was a composite of cardiac death, myocardial infarction, unstable angina and stroke (cardiovascular events) at 30 days after surgery and during late follow-up. Median follow-up was 12 (interquartile range 2-28) months.

RESULTS

New-onset AF was noted in 15 (4.7%) patients. All but three patients returned spontaneously to sinus rhythm. The composite endpoint of cardiovascular events within 30 days and during late follow-up occurred in 34 (11%) and 62 (20%) patients, respectively. Multivariate regression analysis showed that new-onset AF was associated with perioperative (hazard ratio (HR) 6.0; 95% CI: 2.4-15) and late cardiovascular events (HR 4.2, 95% CI: 2.1-8.8).

CONCLUSION

New-onset AF during vascular surgery is associated with an increased incidence of 30-day and late cardiovascular events.

Atrial fibrillation following elective open abdominal aortic aneurysm repair

BACKGROUND

Atrial fibrillation is a common complication following major vascular surgery. It is often considered to be relatively benign but may represent the first sign of cardiac and non-cardiac complications. We conducted a retrospective study to determine the incidence and clinical associations of atrial fibrillation following open elective abdominal aortic aneurysm repair as well as its effect on prognosis.

METHODS

The case-notes of 200 consecutive patients undergoing open aneurysm repair were reviewed. Known pre-operative and intra-operative risk factors and potential post-operative associations with new-onset AF were recorded. Significant univariate correlates with AF were entered into a forward stepwise logistic regression model to test for independence. The effect of new-onset AF on long-term prognosis was assessed.

RESULTS

AF developed in 20 patients (10%) post-operatively. Previous cerebrovascular disease, aneurysm size and post-operative cardiac failure were associated with post-operative AF in univariate analyses. Cerebrovascular disease and post-operative cardiac failure were independently associated with new-onset AF. AF patients had a longer hospital stay. There was no difference in survival between those patients with and without new-onset AF.

CONCLUSION

New-onset AF is a common complication of open abdominal aortic aneurysm surgery and may indicate an underlying myocardial infarction. It is associated with a longer hospital stay and an increased risk of cardiac failure. Assessed and treated appropriately, it appears to have no effect on long-term prognosis.

Atrial Fibrillation After Aortic Arch Repair Requiring Deep Hypothermic Circulatory Arrest: Incidence, Clinical Outcome, and Clinical Predictors

OBJECTIVE

To delineate the incidence, outcome impact, and clinical predictors of atrial fibrillation (AF) after adult aortic arch repair requiring deep hypothermic circulatory arrest (AAR-DHCA) AIMS: To determine the incidence of AF after AAR-DHCA, to determine whether AF after AAR-DHCA affects mortality or stay in the intensive care unit (ICU), to determine multivariate predictors for AF after AAR-DHCA, and to determine whether aprotinin protects against AF after AAR-DHCA.

STUDY DESIGN

Retrospective and observational.

STUDY SETTING

Single large university hospital.

PARTICIPANTS

All adults undergoing AAR-DHCA in 2000 and 2001.

MAIN RESULTS

The cohort size was 144. Antifibrinolytic exposure was 100%, aprotinin 66% and aminocaproic acid 34%. The incidence of AF was 34.0%. AF was not significantly associated with increased mortality or prolonged ICU stay. Advanced age was a multivariate risk factor for AF. Lower temperature nadir during DHCA was protective against postoperative AF. Aprotinin had no demonstrable effect on AF after AAR-DHCA.

CONCLUSIONS

AF after AAR-DHCA is common but does not independently increase mortality or ICU stay. The risk of AF after AAR-DHCA increases with age but decreases with the degree of hypothermia during DHCA. Aprotinin does not appear to affect the risk of AF after AAR-DHCA.

Postoperative arrhythmias in general surgical patients

INTRODUCTION

New-onset arrhythmias are a common problem in cardiothoracic surgery. They are also common following major non-cardiac surgery. This review examines the available literature to establish the incidence and significance of new-onset arrhythmias following major non-cardiothoracic surgery.

MATERIALS AND METHODS

A literature search was performed using the Medline and Pubmed databases using the terms 'post-operative arrhythmia', 'peri-operative arrhythmia', 'atrial fibrillation/flutter', 'supraventricular arrhythmia/tachycardia', 'cardiac complications' and 'non-cardiothoracic surgery'. Articles were cross-referenced for additional relevant publications and reviewed for data regarding new-onset arrhythmias following major non-cardiothoracic surgery.

RESULTS

There was considerable heterogeneity in the literature regarding cardiac monitoring, types of arrhythmias considered and potential associations investigated, thus hindering interpretation. The available data suggest that new-onset arrhythmias affect about 7% of patients following major non-cardiothoracic surgery. These arrhythmias are often associated with other underlying complications.

Supraventricular arrhythmias in intensive care unit patients: short and long-term consequences

BACKGROUND

Supraventricular arrhythmias (SVA), including atrial fibrillation and flutter, are common in surgical and nonsurgical intensive care unit (ICU) patients. There is increased mortality among surgical ICU patients who develop new-onset atrial arrhythmias after noncardiac, non-thoracic surgery. We sought to determine the preadmission and intra-ICU factors associated with the development of new-onset SVA and mortality in these patients.

METHODS

Consecutive patients (n = 611) admitted to a general ICU of a tertiary care hospital were prospectively followed until hospital discharge for evidence of SVA, potential etiologies of these arrhythmias, and consequences of the arrhythmias. Excluded were patients who sustained recent cardiac/thoracic surgery or trauma to the thorax. Long-term survival rates (48 mo from the date of hospitalization) were also determined.

RESULTS

Fifty-two (9%) patients developed new-onset SVA and 75 (12%) had prehospital admission histories of SVA. Eighty-seven (18%) of those without SVA died while hospitalized, while 29 (56%) and 23 (31%) of those with new-onset and histories of SVA, respectively, died while hospitalized. ICU mortality in all groups was associated with sepsis, acute renal failure, myocardial ischemia, and high APACHE II scores. The APACHE II scores were higher (23 +/- 8 [sd]) in new-onset SVA than in the group without SVA (16 +/- 8, P < 0.05). Within a year of hospital admission 65% in the new-onset, 50% in the SVA history, and 20% in the no-SVA groups died.

CONCLUSIONS

New-onset SVA occur frequently in ICU patients and are markers of extremely high in-hospital and 1-yr mortality.

Impact of volume status on the incidence of atrial fibrillation following aortic arch repair

We evaluated the volume status of patients undergoing aortic arch repair to determine the impact of fluid balance on risk of postoperative atrial fibrillation (AF). From 1993, 445 patients who underwent total aortic arch repair were enrolled in this study. Patients who had AF preoperatively or died within the 10th postoperative day (POD) were excluded. Volumes administered (input) and eliminated (output) through all routes were recorded, and fluid balance (input minus output) was calculated intraoperatively, on the day of surgery, and PODs 1-2. The incidence of new onset of AF was 53.9% (240/445). Total input on POD 1 was greater in patients developing AF than in those not developing it (3,372 +/- 90 vs 3,012 +/- 79; P = 0.0036), as was net fluid balance on POD 1 as well (-806 +/- 84 vs -558 +/- 90; P = 0.050). Blood transfusion volume was greater in patients developing AF than in those not developing it on POD 1 (1,285 +/- 89 vs 927 +/- 74; P = 0.003) and POD 2 (405 +/- 53 vs 227 +/- 47; P = 0.015). Increased input volume and net fluid balance on POD 1 are associated with an increased risk of postoperative AF in patients undergoing aortic arch surgery.

Prediction and Incidence of Atrial Fibrillation After Aortic Arch Repair

BACKGROUND

Although atrial fibrillation is often associated with increased morbidity after open heart surgery, neither the incidence nor the clinical consequences of atrial fibrillation after aortic surgery has been well investigated. The goal of this study was to elucidate the risks for incidence of postoperative atrial fibrillation after aortic arch repair.

METHODS

From January 1993 to February 2004, 483 patients with atherosclerotic aortic arch aneurysm (n = 327) or aortic dissection (n = 156) underwent total aortic arch repair. All patients operated on as elective, urgent, or emergency aortic arch repair were included. One hundred sixteen patients received surgery on an emergency basis because of rupture or acute type A dissection. Twenty-four patients had atrial fibrillation preoperatively. Potential predictors of postoperative atrial fibrillation were estimated by a logistic regression model.

RESULTS

The incidence of postoperative, new onset of atrial fibrillation was 52.7% (242 of 459). The length of postoperative hospital stay was longer in patients with postoperative atrial fibrillation (48 +/- 52 days) than in patients without it (35 +/- 29 days; p = 0.001). The length of intensive care unit stay was also longer in patients with postoperative atrial fibrillation (12.1 +/- 23.2) than in patients without it (6.2 +/- 8.8; p = 0.002). Advanced age (p = 0.007; odds ratio = 1.34; 95% confidence interval: 1.14 to 1.62, per 10 years) was the only risk factor that correlated with postoperative new onset of atrial fibrillation.

CONCLUSIONS

Atrial fibrillation was not uncommon after aortic arch repair. Advanced age was the only preoperative risk factor for postoperative atrial fibrillation.