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Halonen J, Kärkkäinen J, Jäntti H, Martikainen T, Valtola A, Ellam S, Väliaho E, Santala E, Räsänen J, Juutilainen A, Mahlamäki V, Vasankari S, Vasankari T, Hartikainen J. Prevention of Atrial Fibrillation After Cardiac Surgery: A Review of Literature and Comparison of Different Treatment Modalities. Cardiol Rev 2024; 32:248-256. [PMID: 36729126 DOI: 10.1097/crd.0000000000000499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Atrial fibrillation is the most common arrhythmia to occur after cardiac surgery, with an incidence of 10% to 50%. It is associated with postoperative complications including increased risk of stroke, prolonged hospital stays and increased costs. Despite new insights into the mechanisms of atrial fibrillation, no specific etiologic factor has been identified as the sole perpetrator of the arrhythmia. Current evidence suggests that the pathophysiology of atrial fibrillation in general, as well as after cardiac surgery, is multifactorial. Studies have also shown that new-onset postoperative atrial fibrillation following cardiac surgery is associated with a higher risk of short-term and long-term mortality. Furthermore, it has been demonstrated that prophylactic medical therapy decreases the incidence of postoperative atrial fibrillation after cardiac surgery. Of note, the incidence of postoperative atrial fibrillation has not changed during the last decades despite the numerous preventive strategies and operative techniques proposed, although the perioperative and postoperative care of cardiac patients as such has improved.
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Affiliation(s)
- Jari Halonen
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Jussi Kärkkäinen
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Helena Jäntti
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
- Centre for Prehospital Emergency Care, Kuopio University Hospital, Kuopio, Finland
| | - Tero Martikainen
- Department of Anesthesiology and Operative Services, Kuopio University Hospital, Kuopio, Finland
| | - Antti Valtola
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Sten Ellam
- Department of Anesthesiology and Operative Services, Kuopio University Hospital, Kuopio, Finland
| | - Eemu Väliaho
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Elmeri Santala
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Jenni Räsänen
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Auni Juutilainen
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Visa Mahlamäki
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Sini Vasankari
- Department of Clinical Medicine, University of Turku, Turku, Finland
| | - Tommi Vasankari
- The UKK Institute for Health Promotion Research, Tampere, Finland
- The Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Juha Hartikainen
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
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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:S2405-500X(24)00162-2. [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] [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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Almassi GH, Quin JA, Stock EM, DeMatt EJ, Biswas K, Hattler B, Tseng E, Zenati MA. Impact of Oral Anticoagulation on Clinical Outcomes in Postoperative Atrial Fibrillation. J Surg Res 2024; 295:122-130. [PMID: 38007859 DOI: 10.1016/j.jss.2023.10.016] [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: 04/30/2023] [Revised: 09/14/2023] [Accepted: 10/28/2023] [Indexed: 11/28/2023]
Abstract
INTRODUCTION The impact of postoperative oral anticoagulation (OAC) with warfarin on postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) was the focus of this examination of patients from the randomized endo-vein graft prospective (REGROUP) Trial. MATERIAL AND METHODS REGROUP was a prospective randomized Veterans Affairs cooperative study comparing endoscopic versus open vein harvest in elective CABG patients (March 2014-April 2017) at 16 Veterans Affairs facilities. This study compared new-onset POAF patients who were treated with warfarin versus no-warfarin. Outcomes included stroke during active follow-up and a major adverse cardiac event composite of mortality, acute myocardial infarction, and repeat revascularization during active and passive follow-up. RESULTS Of the 316/1103 (28.6%) of REGROUP patients who developed new-onset POAF, 45 patients were excluded - mainly for preoperative warfarin use. Of the remaining 269 patients, 85 received OAC with warfarin (OAC group); 184 did not (no-OAC group). Stroke rates during active follow-up (32 [IQR 24-38] mo) were 3.5% OAC group versus 5.4% no-OAC group (P = 0.76); major adverse cardiac eventrates were 20% OAC versus 11.4% no-OAC (P = 0.06). On longer follow-up of (median 4.61 [IQR 3.9-5.1] y), discharge OAC use was associated with all-cause mortality after adjusting for Society of Thoracic Surgeons mortality risk (20.0% versus 11.4% no-OAC use; HR = 2.00, 95% CI: 1.05-3.81, P = 0.035). CONCLUSIONS REGROUP patients with POAF treated with OAC had similar stroke and higher mortality rates versus no-OAC patients. Further investigation of the risk-benefit ratio of OAC in post-CABG patients and which POAF patient subgroups might derive the most benefit with anticoagulation appears warranted.
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Affiliation(s)
- G Hossein Almassi
- Division of Cardiothoracic Surgery, Zablocki Veterans Affairs (VA) Medical Center, Milwaukee, Wisconsin; Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Jacquelyn A Quin
- Department of Surgery, VA Boston Healthcare System, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Eileen M Stock
- Cooperative Studies Program, Perry Point/Baltimore Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, Maryland
| | - Ellen J DeMatt
- Cooperative Studies Program, Perry Point/Baltimore Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, Maryland
| | - Kousick Biswas
- Cooperative Studies Program, Perry Point/Baltimore Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, Maryland
| | - Brack Hattler
- Department of Medicine, Rocky Mountain Regional VA Medical Center, Aurora, Colorado; University of Colorado Anschutz School of Medicine, Aurora, Colorado
| | - Elaine Tseng
- Cardiothoracic Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, California; Department of Surgery, University of California in San Francisco, San Francisco, California
| | - Marco A Zenati
- Department of Surgery, VA Boston Healthcare System, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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Abouzid MR, Vyas A, Eldahtoury S, Anwar J, Naccour S, Elshafei S, Memon A, Subramaniam V, Bennett W, Morin DP, Lavie CJ, Nwaukwa C. Which should you choose for post operative atrial fibrillation, carvedilol or metoprolol? A systemic review and meta-analysis. Curr Probl Cardiol 2024; 49:102220. [PMID: 37989396 DOI: 10.1016/j.cpcardiol.2023.102220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 11/18/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is the most common arrhythmic complication following cardiac surgery. Current guidelines suggest beta-blockers for the prevention of POAF. In comparing metoprolol succinate with carvedilol, the later has sparked interest in its usage as an important medication for POAF prevention. METHODS We considered randomized controlled studies (RCTs) and retrospective studies that evaluated the efficacy of carvedilol versus metoprolol for the prevention of POAF. After literature search, data extraction, and quality evaluation, pooled data were analyzed using either the fixed-effect or random-effect model using Review Manager 5.3. The Cochrane risk of bias tool was used to assess the bias of included studies. The incidence of POAF was the primary endpoint, while mortality rate and bradycardia were secondary outcomes. RESULTS In meta-analysis 5 RCTs and 2 retrospective studies with a total of 1000 patients were included. The overall effect did not favor the carvedilol over metoprolol groups in terms of mortality rate [risk ratio 0.45, 95 % CI (0.1-1.97), P=0.29] or incidence of bradycardia [risk ratio 0.63, 95 % CI (0.32-1.23), P=0.17]. However, the incidence of POAF was lower in patients who received carvedilol compared to metoprolol [risk ratio 0.54, 95 % CI (0.42-0.71), P < 0.00001]. CONCLUSION In patients undergoing cardiac surgery, carvedilol may minimize the occurrence of POAF more effectively than metoprolol. To definitively establish the efficacy of carvedilol compared to metoprolol and other beta-blockers in the prevention of POAF, a large-scale, well-designed randomized controlled trials are required.
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Affiliation(s)
- Mohamad Riad Abouzid
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States
| | - Ankit Vyas
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States
| | - Samar Eldahtoury
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States
| | - Junaid Anwar
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States
| | - Shereen Naccour
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States
| | - Shorouk Elshafei
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States
| | - Areeba Memon
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States
| | - Venkat Subramaniam
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States
| | - William Bennett
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States
| | - Daniel P Morin
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States
| | - Carl J Lavie
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States
| | - Chima Nwaukwa
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States.
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Singh H, Shahid MZ, Harrison SL, Lane DA, Lip GYH, Logantha SJRJ. Subclinical thyroid dysfunction and the risk of incident atrial fibrillation: A systematic review and meta-analysis. PLoS One 2024; 19:e0296413. [PMID: 38165911 PMCID: PMC10760776 DOI: 10.1371/journal.pone.0296413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/12/2023] [Indexed: 01/04/2024] Open
Abstract
BACKGROUND Thyroid hormones act on the cardiovascular system directly by modulating its function and indirectly by transcriptional regulation of gene expression in the heart and the vasculature. Studies have shown associations between overt and subclinical thyroid disorders and cardiovascular outcomes. The aim of this study was to perform a systematic review and meta-analysis to assess the potential relationships between subclinical hyper- and hypothyroidism and risk of atrial fibrillation (AF), and post-operative AF. METHODS MEDLINE and Scopus databases were searched from inception to 18th February 2023 for randomised controlled trials, case-control studies, and cohort studies which assessed the relationship between subclinical thyroid dysfunction and incident AF events. Risk of bias and the quality of evidence were assessed using the RoBANS tool and GRADE approach, respectively. Meta-analysis was conducted in Review Manager 5.4 using the Mantel-Haenszel statistical method and a random-effects model. Data are presented as risk ratios with 95% confidence intervals. Statistical heterogeneity amongst studies was assessed by the chi-squared (χ2) test and I2 statistic. p≤0.05 were considered significant. RESULTS A total of 6467 records were identified, of which 10 cohort studies met the inclusion criteria. Both subclinical hyperthyroidism and subclinical hypothyroidism were associated with an increased risk of incident AF (risk ratio (RR), 1.99; 95% confidence interval (CI), 1.43-2.77; n = 5 studies; p<0.0001 and RR, 1.19; CI, 1.03-1.39; n = 7 studies; p = 0.02, respectively). Subgroup analysis for post-operative AF revealed marked heterogeneity between studies (I2 = 84%) and association with subclinical hypothyroidism was not significant (RR, 1.41; CI, 0.89-2.22; n = 3 studies; p = 0.15). CONCLUSIONS The current evidence suggests that both subclinical hyperthyroidism and subclinical hypothyroidism are associated with increased risk of incident AF. Further investigation is required to determine potential causal links that would guide future clinical practice.
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Affiliation(s)
- Hasveer Singh
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Mariam Z. Shahid
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
- Geriatric Medicine, Airedale General Hospital, Airedale Hospital Trusts, Bradford, United Kingdom
| | - Stephanie L. Harrison
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Deirdre A. Lane
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
- Danish Center for Health Services Research, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
- Danish Center for Health Services Research, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Sunil Jit R. J. Logantha
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
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Parent S, Vaka R, St Amant J, Kahn S, Van Remortel S, Bi C, Courtman D, Stewart DJ, Davis DR. Inactivation of the NLRP3 inflammasome mediates exosome-based prevention of atrial fibrillation. Theranostics 2024; 14:608-621. [PMID: 38169629 PMCID: PMC10758048 DOI: 10.7150/thno.89520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/07/2023] [Indexed: 01/05/2024] Open
Abstract
Rationale: Extracellular vesicles (EVs) from human explant-derived cells injected directly into the atria wall muscle at the time of open chest surgery reduce atrial fibrosis, atrial inflammation, and atrial fibrillation (AF) in a rat model of sterile pericarditis. Albeit a promising solution to prevent postoperative AF, the mechanism(s) underlying this effect are unknown and it is not clear if this benefit is dependent on EV dose. Methods: To determine the dose-efficacy relationship of EVs from human explant-derived cells in a rat model of sterile pericarditis. Increasing doses of EVs (106, 107, 108 or 109) or vehicle control were injected into the atria of middle-age male Sprague-Dawley rats at the time of talc application. A sham control group was included to demonstrate background inducibility. Three days after surgery, all rats underwent invasive electrophysiological testing prior to sacrifice. Results: Pericarditis increased the likelihood of inducing AF (p<0.05 vs. sham). All doses decreased the probability of inducing AF with maximal effects seen after treatment with the highest dose (109, p<0.05 vs. vehicle). Pericarditis increased atrial fibrosis while EV treatment limited the effect of pericarditis on atrial fibrosis with maximal effects seen after treatment with 108 or 109 EVs. Increasing EV dose was associated with progressive decreases in pro-inflammatory cytokine content, inflammatory cell infiltration, and oxidative stress. EVs decreased NLRP3 (NACHT, LRR, and PYD domains-containing protein-3) inflammasome activation though a direct effect on resident atrial fibroblasts and macrophages. This suppressive effect was exclusive to EVs produced by heart-derived cells as application of EVs from bone marrow or umbilical cords did not alter NLRP3 activity. Conclusions: Intramyocardial injection of incremental doses of EVs at the time of open chest surgery led to progressive reductions in atrial fibrosis and inflammatory markers. These effects combined to render atria resistant to the pro-arrhythmic effects of pericarditis which is mechanistically related to suppression of the NLRP3 inflammasome.
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Affiliation(s)
- Sandrine Parent
- University of Ottawa Heart Institute, Division of Cardiology, Department of Medicine, University of Ottawa, Ottawa, CANADA K1Y4W7
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada, K1H8M5
| | - Ramana Vaka
- University of Ottawa Heart Institute, Division of Cardiology, Department of Medicine, University of Ottawa, Ottawa, CANADA K1Y4W7
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada, K1H8M5
| | - Jennifer St Amant
- University of Ottawa Heart Institute, Division of Cardiology, Department of Medicine, University of Ottawa, Ottawa, CANADA K1Y4W7
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada, K1H8M5
| | - Saad Kahn
- Ottawa Hospital Research Institute, Regenerative Medicine Program, Ottawa, Canada, K1H8L6
| | - Sophie Van Remortel
- University of Ottawa Heart Institute, Division of Cardiology, Department of Medicine, University of Ottawa, Ottawa, CANADA K1Y4W7
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada, K1H8M5
| | - Christina Bi
- University of Ottawa Heart Institute, Division of Cardiology, Department of Medicine, University of Ottawa, Ottawa, CANADA K1Y4W7
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada, K1H8M5
| | - David Courtman
- Ottawa Hospital Research Institute, Regenerative Medicine Program, Ottawa, Canada, K1H8L6
| | - Duncan John Stewart
- University of Ottawa Heart Institute, Division of Cardiology, Department of Medicine, University of Ottawa, Ottawa, CANADA K1Y4W7
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada, K1H8M5
- Ottawa Hospital Research Institute, Regenerative Medicine Program, Ottawa, Canada, K1H8L6
| | - Darryl Raymond Davis
- University of Ottawa Heart Institute, Division of Cardiology, Department of Medicine, University of Ottawa, Ottawa, CANADA K1Y4W7
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada, K1H8M5
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7
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Pastore MC, Degiovanni A, Grisafi L, Renda G, Sozzani M, Giordano A, Salvatici C, Lorenz V, Pierfelice F, Cappelli C, De Donno F, Focardi M, Ricci F, Benedetto U, Gallina S, Cameli M, Patti G. Left Atrial Strain to Predict Postoperative Atrial Fibrillation in Patients Undergoing Coronary Artery Bypass Grafting. Circ Cardiovasc Imaging 2024; 17:e015969. [PMID: 38227692 DOI: 10.1161/circimaging.123.015969] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/06/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery being associated with poorer outcomes. Revealing before the operation of left atrial subtle structural/functional abnormalities may help to identify patients at increased risk of POAF. We investigated the role of left atrial strain parameters by preoperative speckle tracking echocardiography as independent predictors of POAF in patients undergoing coronary artery bypass graft. METHODS Consecutive patients undergoing isolated coronary artery bypass graft were prospectively enrolled at three Italian centers. All patients underwent transthoracic echocardiography before the operation. The occurrence of POAF up to discharge was monitored. RESULTS Overall, a total of 310 patients were included. POAF was demonstrated in 103 patients (33%). At receiver operating characteristic curve analysis, lower global peak atrial longitudinal strain (PALS) values significantly predicted the risk of POAF (area under the curve, 0.74; P<0.001). The optimal cutoff value for the arrhythmia prediction was a global PALS value <28%, with a specificity of 86% and a sensitivity of 36%. The incidence of POAF was 51% in patients with global PALS <28% versus 14% in those with PALS ≥28% (P<0.001), with a POAF-free survival at Kaplan-Meier analysis of 45.4% and 85.7%, respectively (P<0.001). At multivariate analysis, a global PALS <28% carried a 3.6-fold higher risk of POAF (hazard ratio, 3.6 [95% CI, 2.2-5.9]; P<0.001). The risk increase was even higher when PALS <28% was associated with age ≥70 years (adjusted hazard ratio, 11.2 [4.7-26.6], P<0.001). CONCLUSIONS A presurgery global PALS <28% is a specific parameter to stratify patients at increased risk of POAF after coronary artery bypass graft. This assessment can be useful to identify patients at higher arrhythmic risk in whom perioperative preventive strategies and stricter monitoring aimed at early diagnosing and treating POAF may be applied.
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Affiliation(s)
- Maria Concetta Pastore
- University of Eastern Piedmont, Novara (M.C.P., L.G., M.S., A.G., G.P.)
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena (M.C.P., C.S., M.F., M.C.)
| | - Anna Degiovanni
- Department of Cardio-Thoracic and Vascular Diseases, Maggiore della Carità Hospital, Novara (A.D., L.G., G.P.)
| | - Leonardo Grisafi
- University of Eastern Piedmont, Novara (M.C.P., L.G., M.S., A.G., G.P.)
- Department of Cardio-Thoracic and Vascular Diseases, Maggiore della Carità Hospital, Novara (A.D., L.G., G.P.)
| | - Giulia Renda
- Department of Neuroscience, Imaging and Clinical Sciences, G. d'Annunzio University of Chieti-Pescara, Chieti (G.R., F.P., C.C., F.D.D., F.R., U.B., S.G.)
- Division of Cardiology, SS. Annunziata Hospital, Chieti (G.R., F.P., C.C., F.D.D., F.R., S.G.)
| | - Martina Sozzani
- University of Eastern Piedmont, Novara (M.C.P., L.G., M.S., A.G., G.P.)
| | - Andrea Giordano
- University of Eastern Piedmont, Novara (M.C.P., L.G., M.S., A.G., G.P.)
| | - Cosimo Salvatici
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena (M.C.P., C.S., M.F., M.C.)
| | - Veronica Lorenz
- Division of Cardio-Thoracic Surgery, Department of Medical Biotechnologies, Azienda Ospedaliera Universitaria Senese, Siena (V.L.)
| | - Francesca Pierfelice
- Department of Neuroscience, Imaging and Clinical Sciences, G. d'Annunzio University of Chieti-Pescara, Chieti (G.R., F.P., C.C., F.D.D., F.R., U.B., S.G.)
- Division of Cardiology, SS. Annunziata Hospital, Chieti (G.R., F.P., C.C., F.D.D., F.R., S.G.)
| | - Clelia Cappelli
- Department of Neuroscience, Imaging and Clinical Sciences, G. d'Annunzio University of Chieti-Pescara, Chieti (G.R., F.P., C.C., F.D.D., F.R., U.B., S.G.)
- Division of Cardiology, SS. Annunziata Hospital, Chieti (G.R., F.P., C.C., F.D.D., F.R., S.G.)
| | - Federica De Donno
- Department of Neuroscience, Imaging and Clinical Sciences, G. d'Annunzio University of Chieti-Pescara, Chieti (G.R., F.P., C.C., F.D.D., F.R., U.B., S.G.)
- Division of Cardiology, SS. Annunziata Hospital, Chieti (G.R., F.P., C.C., F.D.D., F.R., S.G.)
| | - Marta Focardi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena (M.C.P., C.S., M.F., M.C.)
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, G. d'Annunzio University of Chieti-Pescara, Chieti (G.R., F.P., C.C., F.D.D., F.R., U.B., S.G.)
- Division of Cardiology, SS. Annunziata Hospital, Chieti (G.R., F.P., C.C., F.D.D., F.R., S.G.)
| | - Umberto Benedetto
- Department of Neuroscience, Imaging and Clinical Sciences, G. d'Annunzio University of Chieti-Pescara, Chieti (G.R., F.P., C.C., F.D.D., F.R., U.B., S.G.)
- Division of Cardiac Surgery, SS. Annunziata Hospital, Chieti; Italy (U.B.)
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, G. d'Annunzio University of Chieti-Pescara, Chieti (G.R., F.P., C.C., F.D.D., F.R., U.B., S.G.)
- Division of Cardiology, SS. Annunziata Hospital, Chieti (G.R., F.P., C.C., F.D.D., F.R., S.G.)
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena (M.C.P., C.S., M.F., M.C.)
| | - Giuseppe Patti
- University of Eastern Piedmont, Novara (M.C.P., L.G., M.S., A.G., G.P.)
- Department of Cardio-Thoracic and Vascular Diseases, Maggiore della Carità Hospital, Novara (A.D., L.G., G.P.)
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8
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Aggarwal R, Siems C, Potel KN, Hingtgen A, Wang Q, Nijjar PS, Huddleston SJ, John R, Kelly RF, Voeller RK. New-onset postoperative atrial fibrillation after mitral valve surgery: Determinants and the effect on survival. JTCVS OPEN 2023; 16:305-320. [PMID: 38204696 PMCID: PMC10775066 DOI: 10.1016/j.xjon.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 07/29/2023] [Accepted: 08/28/2023] [Indexed: 01/12/2024]
Abstract
Objective Mitral valve surgery (MVS) carries substantial risk of postoperative atrial fibrillation (PAF). Identifying patients who benefit from prophylactic left atrial appendage amputation (LAAA) or maze is ill-defined. To guide such interventions, we determined preoperative predictors of PAF and investigated 3-year survival of patients with PAF. Methods We performed a retrospective analysis of patients undergoing isolated MVS (N = 670) between 2011 and 2021. Patients with preoperative atrial fibrillation, LAAA or pulmonary vein isolation were excluded. Patient characteristics were compared between those without PAF and those who developed transient or prolonged PAF. Predictors of any PAF and prolonged PAF were identified using multivariable regression analysis. Results In total, 504 patients without preoperative atrial fibrillation underwent isolated MVS. Of them, 303 patients (60.2%) developed PAF; 138 (27.3%) developed transient and 165 (32.7%) developed prolonged (beyond 30 days) PAF. Patients with PAF were older (65.7 vs 54.3 years, P < .001), with larger left atria (4.8 vs 4.3 cm, P < .001), greater prevalence of hypertension (60% vs 47.8%, P < .05), and were New York Heart Association class III/IV (36% vs 8.5%, P < .001). Independent predictors of PAF included left atria volume index (odds ratio [OR], 1.02; P < .003), older age (OR, 1.04; P < .001), heart failure (OR, 6.73; P < .001), and sternotomy (OR, 2.19; P < .002). Age, heart failure, and sternotomy were independent predictors of prolonged PAF. Patients with PAF had greater mortality at 3 years compared with those without PAF (5.3% vs 0.5%, P < .005). On multivariable analysis, PAF was associated with increased mortality (hazard ratio, 7.81; P < .046). Conclusions PAF is common after MVS and associated with late mortality. Older age, advanced heart failure, and sternotomy are associated with prolonged PAF. These factors may identify patients who would benefit from prophylactic LAAA or ablation during MVS.
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Affiliation(s)
- Rishav Aggarwal
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn
| | - Chesney Siems
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn
| | - Koray N. Potel
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | | | - Qi Wang
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minn
| | - Prabhjot S. Nijjar
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minn
| | - Stephen J. Huddleston
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn
| | - Ranjit John
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn
| | - Rosemary F. Kelly
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn
| | - Rochus K. Voeller
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn
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9
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Segar MW, Marzec A, Razavi M, Mullins K, Molina-Razavi JE, Chatterjee S, Shafii AE, Cozart JR, Moon MR, Rasekh A, Saeed M. Incidence, Risk Score Performance, and In-Hospital Outcomes of Postoperative Atrial Fibrillation After Cardiac Surgery. Tex Heart Inst J 2023; 50:e238221. [PMID: 37885133 PMCID: PMC10658140 DOI: 10.14503/thij-23-8221] [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] [Indexed: 10/28/2023]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) frequently complicates cardiac surgery. Predicting POAF can guide interventions to prevent its onset. This study assessed the incidence, risk factors, and related adverse outcomes of POAF after cardiac surgery. METHODS A cohort of 1,606 patients undergoing cardiac surgery at a tertiary referral center was analyzed. Postoperative AF was defined based on the Society of Thoracic Surgeons' criteria: AF/atrial flutter after operating room exit that either lasted longer than 1 hour or required medical or procedural intervention. Risk factors for POAF were evaluated, and the performance of established risk scores (POAF, HATCH, COM-AF, CHA2DS2-VASc, and Society of Thoracic Surgeons risk scores) in predicting POAF was assessed using discrimination (area under the receiver operator characteristics curve) analysis. The association of POAF with secondary outcomes, including length of hospital stay, ventilator time, and discharge to rehabilitation facilities, was evaluated using adjusted linear and logistic regression models. RESULTS The incidence of POAF was 32.2% (n = 517). Patients who developed POAF were older, had traditional cardiovascular risk factors and higher Society of Thoracic Surgeons risk scores, and often underwent valve surgery. The POAF risk score demonstrated the highest area under the receiver operator characteristics curve (0.65), but risk scores generally underperformed. Postoperative AF was associated with extended hospital stays, longer ventilator use, and higher likelihood of discharge to rehabilitation facilities (odds ratio, 2.30; 95% CI, 1.73-3.08). CONCLUSION This study observed a high incidence of POAF following cardiac surgery and its association with increased morbidity and resource utilization. Accurate POAF prediction remains elusive, emphasizing the need for better risk-prediction methods and tailored interventions to diminish the effect of POAF on patient outcomes.
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Affiliation(s)
- Matthew W. Segar
- Department of Cardiology, The Texas Heart Institute, Houston, Texas
| | - Alexander Marzec
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Mehdi Razavi
- Department of Cardiology, The Texas Heart Institute, Houston, Texas
| | - Karen Mullins
- Quality Cardiovascular Service Line, Baylor St Luke's Medical Center, Houston, Texas
| | | | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas
| | - Alexis E. Shafii
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas
| | - Jennifer R. Cozart
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas
| | - Marc R. Moon
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas
| | - Abdi Rasekh
- Department of Cardiology, The Texas Heart Institute, Houston, Texas
| | - Mohammad Saeed
- Department of Cardiology, The Texas Heart Institute, Houston, Texas
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10
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Lee S, Khrestian C, Laurita D, Juzbasich D, Wallick D, Waldo A. Validation of a new species for studying postoperative atrial fibrillation: Swine sterile pericarditis model. Pacing Clin Electrophysiol 2023; 46:1003-1009. [PMID: 37377345 DOI: 10.1111/pace.14765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/02/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND The canine sterile pericarditis model associated with atrial inflammation is an experimental counterpart of postoperative atrial fibrillation (POAF). However, the use of canines for research is restricted by ethics committees in many countries, and social acceptance is declining. OBJECTIVE To validate the feasibility of the swine sterile pericarditis model as an experimental counterpart to study POAF. METHODS Seven domestic pigs (35-60 kg) underwent initial pericarditis surgery. On two or more postoperative days in the closed-chest state, we performed electrophysiological measurements of pacing threshold and atrial effective refractory period (AERP) while pacing from the right atrial appendage (RAA) and the posterior left atrium (PLA). The inducibility of POAF (>5 min) by burst pacing was determined in both the conscious and anesthetized closed-chest state. These data were compared to previously published canine sterile pericarditis data for validation. RESULTS The pacing threshold increased from day 1 to day 3 (2 ± 0.1 to 3.3 ± 0.6 mA in the RAA, 2.5 ± 0.1 to 4.8 ± 0.2 mA in the PLA). Also, the AERP increased from day 1 to day 3 (118 ± 8 to 157 ± 16 ms in the RAA; 98 ± 4 to 124 ± 2 ms in the PLA, both p < .05). Induction of sustained POAF occurred in 43% (POAF CL range 74-124 ms). All electrophysiologic data from the swine model were consistent with the canine model with respect to (1) the range of both pacing threshold and AERP; (2) the progressive increase in threshold and AERP over time; (3) a 40%-50% incidence of POAF. CONCLUSION A newly developed swine sterile pericarditis model demonstrated electrophysiologic properties consistent with the canine model and patients after open heart surgery.
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Affiliation(s)
- Seungyup Lee
- Departments of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - Celeen Khrestian
- Departments of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Daniel Laurita
- Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - Dragan Juzbasich
- Departments of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Don Wallick
- Departments of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Albert Waldo
- Departments of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
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11
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Samadifar Z, Aslanabadi N, Kazemi Arbat B, Separham A, Javanshir E. Comparison of the Efficacy of Atorvastatin and Rosuvastatin in Preventing Atrial Fibrillation after Coronary Artery Bypass Grafting: A Double-Blind Randomized Comparative Trial. J Tehran Heart Cent 2023; 18:115-121. [PMID: 37637286 PMCID: PMC10459339 DOI: 10.18502/jthc.v18i2.13321] [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] [Received: 12/27/2021] [Accepted: 08/03/2023] [Indexed: 08/29/2023] Open
Abstract
Background Atrial fibrillation (AF) is a supraventricular tachyarrhythmia characterized by disorganized atrial activity and subsequent mechanical atrial failure. Postoperative AF is a frequent complication of coronary artery bypass grafting (CABG). Although there is evidence of decreased AF after CABG with statin usage, information is scarce regarding a direct comparison between atorvastatin and rosuvastatin. The present study was conducted to compare the efficacy of rosuvastatin and atorvastatin in preventing post-CABG AF. Methods The present double-blind randomized comparative clinical trial selected CABG candidates with stable ischemic heart disease or acute coronary syndromes. Atorvastatin (40 mg per day) or rosuvastatin (20 mg per day) was prescribed 1 week before surgery, and the outcomes were compared. Results Two-hundred patients, 100 cases in each group, completed the study. Twenty-five patients in each group were female, and the mean age was 59.30±8.42 years in the rosuvastatin group and 60.13±9.40 years in the atorvastatin group (P=0.513). The frequency of AF was 31% in the atorvastatin group and 27% in the rosuvastatin group (P=0.534). No significant differences existed between the groups concerning the length of hospital and ICU stay (P=0.333 and P=0.161) and in-hospital and 3-month mortality (P=0.315 and P=0.648). A subgroup analysis of only patients with stable ischemic heart disease could not detect a significant difference between the study groups in any of the investigated outcomes. Our logistic regression analysis showed an association only between age and the incidence of AF after CABG (OR, 1.12; 95% CI, 1.05 to 1.20; P<0.01). Conclusion Rosuvastatin and atorvastatin are similar concerning the prevention of post-CABG AF, but there is a need for future well-designed multicenter studies on this topic.
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Affiliation(s)
- Zahra Samadifar
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Naser Aslanabadi
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Babak Kazemi Arbat
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ahmad Separham
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Elnaz Javanshir
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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12
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Aly K, Shaat M, Hamza S, Ali S. Triggers of Atrial Fibrillation in the Geriatric Medical Intensive Care Unit: An Observational Study. Cardiol Res 2023; 14:106-114. [PMID: 37091882 PMCID: PMC10116932 DOI: 10.14740/cr1461] [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] [Received: 12/31/2022] [Accepted: 02/13/2023] [Indexed: 04/25/2023] Open
Abstract
Background Atrial fibrillation (AF) is a common arrhythmia in the non-cardiac intensive care unit (ICU). However, data concerning AF incidence and predictors in such populations are scarce and controversial. The study aimed to investigate the contributing factors of new-onset AF in elderly patients within the medical intensive care setting. Methods Patients admitted to ICU during a 6-month period were prospectively studied. Patients admitted for short period postoperative monitoring and patients with chronic or paroxysmal AF were excluded. The conditions involved as AF risk factors or "triggers" from demographic data, history, and echocardiography were recorded. Acute Physiology and Chronic Health Evaluation II score was calculated. Electrolytes including some trace elements (zinc, copper, and magnesium) were analyzed. Results The study included 142 patients (49% females). Mean age was 69.5 ± 7.3 years. AF was observed in 12%. Diagnosis of pneumonia (P < 0.001), low copper (P < 0.0001) and low zinc levels (P < 0.0001) was significantly associated with the occurrence of AF. By multivariate analysis, they remained statistically significant (odds ratio, 7.0; 95% confidence interval, 2.0 - 24.6; P < 0.01). Conclusions A significant fraction of ICU elderly patients manifests AF. The relevant factors contributing to AF incidence in the elderly are pneumonia and low zinc and low copper.
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Affiliation(s)
- Khaled Aly
- Cardiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Corresponding Author: Khaled Aly, Cardiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - Maram Shaat
- Geriatrics and Gerontology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Sarah Hamza
- Geriatrics and Gerontology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Safaa Ali
- Geriatrics and Gerontology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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13
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Fields KG, Ma J, Petrinic T, Alhassan H, Eze A, Reddy A, Hedayat M, Providencia R, Lip GYH, Bedford JP, Clifton DA, Redfern OC, O'Brien B, Watkinson PJ, Collins GS, Muehlschlegel JD. Multivariable prediction models for atrial fibrillation after cardiac surgery: a systematic review protocol. BMJ Open 2023; 13:e067260. [PMID: 36914189 PMCID: PMC10016290 DOI: 10.1136/bmjopen-2022-067260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
INTRODUCTION Dozens of multivariable prediction models for atrial fibrillation after cardiac surgery (AFACS) have been published, but none have been incorporated into regular clinical practice. One of the reasons for this lack of adoption is poor model performance due to methodological weaknesses in model development. In addition, there has been little external validation of these existing models to evaluate their reproducibility and transportability. The aim of this systematic review is to critically appraise the methodology and risk of bias of papers presenting the development and/or validation of models for AFACS. METHODS We will identify studies that present the development and/or validation of a multivariable prediction model for AFACS through searches of PubMed, Embase and Web of Science from inception to 31 December 2021. Pairs of reviewers will independently extract model performance measures, assess methodological quality and assess risk of bias of included studies using extraction forms adapted from a combination of the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies checklist and the Prediction Model Risk of Bias Assessment Tool. Extracted information will be reported by narrative synthesis and descriptive statistics. ETHICS AND DISSEMINATION This systemic review will only include published aggregate data, so no protected health information will be used. Study findings will be disseminated through peer-reviewed publications and scientific conference presentations. Further, this review will identify weaknesses in past AFACS prediction model development and validation methodology so that subsequent studies can improve upon prior practices and produce a clinically useful risk estimation tool. PROSPERO REGISTRATION NUMBER CRD42019127329.
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Affiliation(s)
- Kara G Fields
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jie Ma
- Centre for Statistics in Medicine, Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Tatjana Petrinic
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Hassan Alhassan
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Anthony Eze
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Ankith Reddy
- University of Texas Medical Branch, School of Medicine, Galveston, Texas, USA
| | - Mona Hedayat
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rui Providencia
- Institute of Health Informatics Research, University College London, London, UK
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jonathan P Bedford
- Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - David A Clifton
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - Oliver C Redfern
- Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Benjamin O'Brien
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Deutsches Herzzentrum Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Perioperative Medicine, St. Bartholomew's Hospital and Barts Heart Centre, Barts Health NHS Trust, London, UK
- Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Peter J Watkinson
- Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Trust, Oxford, UK
- NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jochen D Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA
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14
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Parise O, Parise G, Vaidyanathan A, Occhipinti M, Gharaviri A, Tetta C, Bidar E, Maesen B, Maessen JG, La Meir M, Gelsomino S. Machine Learning to Identify Patients at Risk of Developing New-Onset Atrial Fibrillation after Coronary Artery Bypass. J Cardiovasc Dev Dis 2023; 10:jcdd10020082. [PMID: 36826578 PMCID: PMC9962068 DOI: 10.3390/jcdd10020082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/18/2023] [Accepted: 02/10/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND This study aims to get an effective machine learning (ML) prediction model of new-onset postoperative atrial fibrillation (POAF) following coronary artery bypass grafting (CABG) and to highlight the most relevant clinical factors. METHODS Four ML algorithms were employed to analyze 394 patients undergoing CABG, and their performances were compared: Multivariate Adaptive Regression Spline, Neural Network, Random Forest, and Support Vector Machine. Each algorithm was applied to the training data set to choose the most important features and to build a predictive model. The better performance for each model was obtained by a hyperparameters search, and the Receiver Operating Characteristic Area Under the Curve metric was selected to choose the best model. The best instances of each model were fed with the test data set, and some metrics were generated to assess the performance of the models on the unseen data set. A traditional logistic regression was also performed to be compared with the machine learning models. RESULTS Random Forest model showed the best performance, and the top five predictive features included age, preoperative creatinine values, time of aortic cross-clamping, body surface area, and Logistic Euro-Score. CONCLUSIONS The use of ML for clinical predictions requires an accurate evaluation of the models and their hyperparameters. Random Forest outperformed all other models in the clinical prediction of POAF following CABG.
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Affiliation(s)
- Orlando Parise
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
- Department of Cardiac Surgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
- Correspondence:
| | - Gianmarco Parise
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | | | | | - Ali Gharaviri
- Institute of Computational Science, Università della Svizzera Italiana, 6900 Lugano, Switzerland
| | - Cecilia Tetta
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | - Elham Bidar
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | - Bart Maesen
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | - Jos G. Maessen
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | - Mark La Meir
- Department of Cardiac Surgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Sandro Gelsomino
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
- Department of Cardiac Surgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
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15
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Zhou Z, Long Y, He X, Li Y. Effects of different doses of glucocorticoids on postoperative atrial fibrillation: a meta-analysis. BMC Cardiovasc Disord 2023; 23:16. [PMID: 36635657 PMCID: PMC9838011 DOI: 10.1186/s12872-022-03001-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 12/09/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is the most common arrhythmia after cardiac surgery, and its occurrence is closely related to inflammation. This paper intends to apply meta-analysis to investigate the effect of glucocorticoids on POAF. METHODS PubMed, Embase, Web of Science, and Cochrane Library were searched using the internationally recognized systematic evaluation and retrieval strategy. Two review authors independently selected relevant studies and extracted data based on the Cochrane handbook for systematic reviews of interventions approach. Stata 17 was used for data analysis. In the subgroup analysis, we grouped the participant data according to differences in glucocorticoids dose and type of surgery. At the same time, we also conducted a meta-analysis on the possible infection and gastrointestinal injury caused by glucocorticoids use. RESULTS 27 studies and 14,442 patients were finally included. Results from the random-effects model indicated that the incidence of POAF was lower in glucocorticoid group (RR 0.80, 95% CI 0.71-0.92, P = 0.001). According to the subgroup analysis result, low doses of glucocorticoids reduced the incidence of POAF (RR 0.81, 95% CI 0.71-0.92, P = 0.001). The effect of high doses glucocorticoids on the POAF was not statistically significant (RR 0.81, 95% CI 0.56-1.19, P = 0.286). In the coronary artery bypass grafting (CABG) subgroup, the glucocorticoids reduced the incidence of POAF (RR 0.71, 95% CI 0.58-0.87, P = 0.001). In the CABG OR Valvular Surgery group, the effect of glucocorticoids on POAF was not statistically significant (RR 0.88, 95% CI 0.75-1.03, P = 0.108). 15 studies documented postoperative complications of infection, two studies were excluded from the system because the end point event was 0, and meta-analysis showed no increased risk of infection from glucocorticoid use (RR 0.85, 95% CI 0.68-1.06, P = 0.158). Eight studies documented the effects of glucocorticoids on gastrointestinal diseases, and meta-analysis showed no differences between the two groups (RR 1.12, 95% CI 0.83-1.50, P = 0.450). CONCLUSION The use of glucocorticoids can reduce the incidence of POAF. The subgroup analysis result showed that low-dose glucocorticoids were more effective than high-dose glucocorticoids in inhibiting POAF. The use of glucocorticoids in CABG alone can better inhibit the occurrence of POAF. The effects of glucocorticoids on infection and gastrointestinal injury were not statistically significant. REVIEW REGISTRATION PROSPERO, CRD42022304521.
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Affiliation(s)
- Zhongzheng Zhou
- Department of Cardiology, Chongqing Traditional Chinese Medicine Hospital, Chongqing, 400025 China
| | - Yi Long
- Department of Cardiology, Chongqing Traditional Chinese Medicine Hospital, Chongqing, 400025 China
| | - Xin He
- Department of Cardiology, Chongqing Traditional Chinese Medicine Hospital, Chongqing, 400025 China
| | - Yong Li
- Department of Cardiology, Chongqing Traditional Chinese Medicine Hospital, Chongqing, 400025 China
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16
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Atrial fibrillation after cardiac surgery: A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2023; 165:94-103.e24. [PMID: 33952399 DOI: 10.1016/j.jtcvs.2021.03.077] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 03/05/2021] [Accepted: 03/12/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE New-onset postoperative atrial fibrillation (POAF) after cardiac surgery is common, with rates up to 60%. POAF has been associated with early and late stroke, but its association with other cardiovascular outcomes is less known. The objective was to perform a meta-analysis of the studies reporting the association of POAF with perioperative and long-term outcomes in patients with cardiac surgery. METHODS We performed a systematic review and a meta-analysis of studies that presented outcomes for cardiac surgery on the basis of the presence or absence of POAF. MEDLINE, EMBASE, and the Cochrane Library were assessed; 57 studies (246,340 patients) were selected. Perioperative mortality was the primary outcome. Inverse variance method and random model were performed. Leave-one-out analysis, subgroup analyses, and metaregression were conducted. RESULTS POAF was associated with perioperative mortality (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.58-2.33), perioperative stroke (OR, 2.17; 95% CI, 1.90-2.49), perioperative myocardial infarction (OR, 1.28; 95% CI, 1.06-1.54), perioperative acute renal failure (OR, 2.74; 95% CI, 2.42-3.11), hospital (standardized mean difference, 0.80; 95% CI, 0.53-1.07) and intensive care unit stay (standardized mean difference, 0.55; 95% CI, 0.24-0.86), long-term mortality (incidence rate ratio [IRR], 1.54; 95% CI, 1.40-1.69), long-term stroke (IRR, 1.33; 95% CI, 1.21-1.46), and longstanding persistent atrial fibrillation (IRR, 4.73; 95% CI, 3.36-6.66). CONCLUSIONS The results suggest that POAF after cardiac surgery is associated with an increased occurrence of most short- and long-term cardiovascular adverse events. However, the causality of this association remains to be established.
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17
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Zhang J, Wang J, Jiang Y, Zheng X, Li W, Li H. Association of Mitral Regurgitation with Postoperative Atrial Fibrillation in Critically Ill Noncardiac Surgery Patients: A Prospective Cohort Study. Int J Gen Med 2023; 16:769-783. [PMID: 36879619 PMCID: PMC9985404 DOI: 10.2147/ijgm.s400122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 02/22/2023] [Indexed: 03/04/2023] Open
Abstract
Purpose Atrial fibrillation (AF) is common in critically ill patients and can have serious consequences. Postoperative AF (POAF) in critically ill patients following noncardiac surgery has been understudied, contrary to cardiac procedures. Mitral regurgitation (MR) is associated with left ventricular dysfunction, which might contribute to the occurrence of AF in postoperative critically ill patients. This study aimed to investigate the association between MR and POAF in critically ill noncardiac surgery patients and establish a new nomogram for the prediction of POAF in critically ill noncardiac surgery patients. Patients and Methods A prospective cohort of 2474 patients who underwent thoracic and general surgery was enrolled in this study. Data on preoperative transthoracic echocardiography (TTE), electrocardiogram (ECG), and several commonly utilized scoring systems (CHA2DS2-VASc, HATCH, COM-AF, HART, and C2HEST) and baseline clinical data were collected. Independent predictors were selected by univariate and multivariable logistic regression analysis, and a nomogram was constructed for POAF within 7 days after postoperative intensive care unit (ICU) admission. The ability of the MR-nomogram and other scoring systems to predict POAF was compared by receiver operator characteristic (ROC) curve analysis and decision curve analysis (DCA). Additional contributions were evaluated by integrated discrimination improvement (IDI) and net reclassification improvement (NRI) analysis. Results A total of 213 (8.6%) patients developed POAF within 7 days after ICU admission. Compared to CHA2DS2-VASc, HATCH, COM-AF, HART, and C2HEST scoring systems, MR-nomogram showed better predictive ability for POAF with an area under the ROC curve of 0.824 (95% confidence interval: 0.805-0.842, p < 0.001). The improvement of the MR-nomogram in predictive value was supported by NRI and IDI analysis. The net benefit of the MR nomogram was maximal in DCA. Conclusion MR is an independent risk factor of POAF in critically ill noncardiac surgery patients. The nomogram predicted POAF better than other scoring systems.
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Affiliation(s)
- Jin Zhang
- Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jingyi Wang
- Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yijia Jiang
- Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xi Zheng
- Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Wenxiong Li
- Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Hui Li
- Thoracic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
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18
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Makita S, Yasu T, Akashi YJ, Adachi H, Izawa H, Ishihara S, Iso Y, Ohuchi H, Omiya K, Ohya Y, Okita K, Kimura Y, Koike A, Kohzuki M, Koba S, Sata M, Shimada K, Shimokawa T, Shiraishi H, Sumitomo N, Takahashi T, Takura T, Tsutsui H, Nagayama M, Hasegawa E, Fukumoto Y, Furukawa Y, Miura SI, Yasuda S, Yamada S, Yamada Y, Yumino D, Yoshida T, Adachi T, Ikegame T, Izawa KP, Ishida T, Ozasa N, Osada N, Obata H, Kakutani N, Kasahara Y, Kato M, Kamiya K, Kinugawa S, Kono Y, Kobayashi Y, Koyama T, Sase K, Sato S, Shibata T, Suzuki N, Tamaki D, Yamaoka-Tojo M, Nakanishi M, Nakane E, Nishizaki M, Higo T, Fujimi K, Honda T, Matsumoto Y, Matsumoto N, Miyawaki I, Murata M, Yagi S, Yanase M, Yamada M, Yokoyama M, Watanabe N, Ito H, Kimura T, Kyo S, Goto Y, Nohara R, Hirata KI. JCS/JACR 2021 Guideline on Rehabilitation in Patients With Cardiovascular Disease. Circ J 2022; 87:155-235. [PMID: 36503954 DOI: 10.1253/circj.cj-22-0234] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Shigeru Makita
- Department of Cardiac Rehabilitation, Saitama Medical University International Medical Center
| | - Takanori Yasu
- Department of Cardiovascular Medicine and Nephrology, Dokkyo Medical University Nikko Medical Center
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Hitoshi Adachi
- Department of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Hideo Izawa
- Department of Cardiology, Fujita Health University of Medicine
| | - Shunichi Ishihara
- Department of Psychology, Bunkyo University Faculty of Human Sciences
| | - Yoshitaka Iso
- Division of Cardiology, Showa University Fujigaoka Hospital
| | - Hideo Ohuchi
- Department of Pediatrics, National Cerebral and Cardiovascular Center
| | | | - Yusuke Ohya
- Department of Cardiovascular Medicine, Nephrology and Neurology, Graduate School of Medicine, University of the Ryukyus
| | - Koichi Okita
- Graduate School of Lifelong Sport, Hokusho University
| | - Yutaka Kimura
- Department of Health Sciences, Kansai Medical University Hospital
| | - Akira Koike
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Masahiro Kohzuki
- Department of Internal Medicine and Rehabilitation Science, Tohoku University Graduate School of Medicine
| | - Shinji Koba
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | - Kazunori Shimada
- Department of Cardiology, Juntendo University School of Medicine
| | | | - Hirokazu Shiraishi
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Tetsuya Takahashi
- Department of Physical Therapy, Faculty of Health Science, Juntendo University
| | - Tomoyuki Takura
- Department of Healthcare Economics and Health Policy, Graduate School of Medicine, The University of Tokyo
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
| | | | - Emiko Hasegawa
- Faculty of Psychology and Social Welfare, Seigakuin University
| | - Yoshihiro Fukumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | | | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Sumio Yamada
- Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine
| | - Yuichiro Yamada
- Center for Diabetes, Endocrinology and Metabolism, Kansai Electric Power Hospital
| | | | | | - Takuji Adachi
- Department of Physical Therapy, Nagoya University Graduate School of Medicine
| | | | | | | | - Neiko Ozasa
- Cardiovascular Medicine, Kyoto University Hospital
| | - Naohiko Osada
- Department of Physical Checking, St. Marianna University Toyoko Hospital
| | - Hiroaki Obata
- Division of Internal Medicine, Niigata Minami Hospital.,Division of Rehabilitation, Niigata Minami Hospital
| | | | - Yusuke Kasahara
- Department of Rehabilitation, St. Marianna University Yokohama Seibu Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kentaro Kamiya
- Department of Rehabilitation, School of Allied Health Sciences, Kitasato University
| | - Shintaro Kinugawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
| | - Yuji Kono
- Department of Rehabilitation, Fujita Health University Hospital
| | - Yasuyuki Kobayashi
- Department of Medical Technology, Gunma Prefectural Cardiovascular Center
| | | | - Kazuhiro Sase
- Clinical Pharmacology and Regulatory Science, Graduate School of Medicine, Juntendo University
| | - Shinji Sato
- Department of Physical Therapy, Teikyo Heisei University
| | - Tatsuhiro Shibata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine
| | - Norio Suzuki
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Daisuke Tamaki
- Department of Nutrition, Showa University Fujigaoka Hospital
| | - Minako Yamaoka-Tojo
- Department of Rehabilitation, School of Allied Health Sciences, Kitasato University
| | - Michio Nakanishi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Mari Nishizaki
- Department of Rehabilitation, National Hospital Organization Okayama Medical Center
| | - Taiki Higo
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
| | - Kanta Fujimi
- Department of Rehabilitation, Fukuoka University Hospital
| | - Tasuku Honda
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Center
| | - Yasuharu Matsumoto
- Department of Cardiovascular Medicine, Shioya Hospital, International University of Health and Welfare
| | | | - Ikuko Miyawaki
- Department of Nursing, Kobe University Graduate School of Health Sciences
| | - Makoto Murata
- Department of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Shusuke Yagi
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | - Masanobu Yanase
- Department of Transplantation, National Cerebral and Cardiovascular Center
| | | | - Miho Yokoyama
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | | | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Syunei Kyo
- Tokyo Metropolitan Geriatric Medical Center
| | | | | | - Ken-Ichi Hirata
- Department of Internal Medicine, Kobe University Graduate School of Medicine
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19
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Gerdisch MW, Garrett HE, Mumtaz MA, Grehan JF, Castillo-Sang M, Miller JS, Zorn GL, Gall SA, Johnkoski JA, Ramlawi B. Prophylactic Left Atrial Appendage Exclusion in Cardiac Surgery Patients With Elevated CHA 2DS 2-VASc Score: Results of the Randomized ATLAS Trial. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:463-470. [PMID: 36373654 DOI: 10.1177/15569845221123796] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Patients with elevated CHA2DS2-VASc scores are at high risk for atrial fibrillation (AF) and thromboembolic events (TE) after cardiac surgery. Left atrial appendage exclusion (LAAE) is a permanent, continuous approach to stroke prevention in AF, overcoming limitations of oral anticoagulation (OAC). We report ATLAS trial results focused on LAAE technical success and perioperative safety and TE rates with and without LAAE in cardiac surgery patients who developed postoperative AF (POAF). METHODS ATLAS (NCT02701062) was a prospective, multicenter, feasibility trial. Patients age ≥18 years, undergoing structural heart procedure, with no preoperative AF, CHA2DS2-VASc ≥2, and HAS-BLED ≥2 were randomized 2:1 to LAAE or no LAAE. Patients who developed POAF and/or received LAAE were followed for 1 year. LAAE was evaluated with intraoperative transesophageal echocardiography. RESULTS A total of 562 patients were randomized to LAAE (n = 376) or no LAAE (n = 186). Mean CHA2DS2-VASc (3.4 vs 3.4) and HAS-BLED (2.8 vs 2.9) scores were similar for LAAE and no LAAE groups. LAAE success (no flow nor residual stump >10 mm) was 99%. One LAAE-related serious adverse event (0.27%) occurred and was resolved without sequelae. There were 44.3% of patients who developed POAF. Through 1 year, 3.4% of LAAE patients and 5.6% of no LAAE patients had TE. OAC was used by 32.5% of POAF patients. Bleeding was higher with OAC than without (16.1% vs 5.4%, P = 0.008). CONCLUSIONS ATLAS demonstrated a high rate of successful LAAE with low LAAE-related serious adverse events in cardiac surgery patients. Study results should be considered in future trial design to further evaluate prophylactic LAAE for stroke prevention in cardiac surgery patients with elevated stroke risk.
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Affiliation(s)
| | | | - Mubashir A Mumtaz
- University of Pittsburgh Medical Center Central PA, Harrisburg, PA, USA
| | | | | | | | - George L Zorn
- University of Kansas Medical Center, Kansas City, KS, USA
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20
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Wakefield BJ, Artis AS, Alfirevic A, Sale S, Duncan AE. Post-cardiopulmonary bypass longitudinal strain provides higher prognostic ability than baseline strain or change in strain. Ann Card Anaesth 2022; 25:505-513. [PMID: 36254918 PMCID: PMC9732967 DOI: 10.4103/aca.aca_295_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 04/20/2021] [Accepted: 05/18/2021] [Indexed: 06/16/2023] Open
Abstract
CONTEXT Global longitudinal strain (GLS) measured by speckle-tracking echocardiography demonstrates excellent prognostic ability in predicting major adverse cardiac events after cardiac surgery. However, the optimal timing of intraoperative GLS measurement that provides the best prognostic value is unclear. AIM Our goal was to evaluate whether GLS measured prior to cardiopulmonary bypass (pre-CPB GLS), following CPB (post-CPB GLS), or change in GLS provides the strongest association with postoperative complications. SETTING AND DESIGN Post hoc analysis of prospectively collected data from a clinical trial (NCT01187329). 72 patients with aortic stenosis undergoing elective AVR ± coronary artery bypass grafting between January 2011 and August 2013. MATERIAL AND METHODS Myocardial deformation analysis from standardized transesophageal echocardiographic examinations were performed after anesthetic induction and chest closure. We evaluated the association between pre-CPB GLS, post-CPB GLS, and change in GLS (percent change from pre-CPB baseline) with postoperative atrial fibrillation and hospitalization >7 days. The association of post-CPB GLS with duration of mechanical ventilation, N-terminal pro-BNP (NT-proBNP) and troponin T were also assessed. STATISTICAL ANALYSIS Multivariable logistic regression. RESULTS Risk-adjusted odds (OR[97.5%CI] of prolonged hospitalization increased an estimated 27% (1.27[1.01 to 1.59];Padj =0.035) per 1% decrease in absolute post-CPB GLS. Mean[98.3%CI] NT-proBNP increased 98.4[20 to 177]pg/mL; Padj =0.008), per 1% decrease in post-CPB GLS. Pre-CPB GLS or change in GLS were not associated with any outcomes. CONCLUSIONS Post-CPB GLS provides the best prognostic value in predicting postoperative outcomes. Measuring post-CPB GLS may improve risk stratification and assist in future study design and patient outcome research.
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Affiliation(s)
- Brett J. Wakefield
- Department of Intensive Care and Resuscitation, Cardiothoracic Anesthesiology, and Quantitative Health Sciences, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA
| | - Amanda S. Artis
- Department of Quantitative Health Sciences, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA
| | - Andrej Alfirevic
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA
| | - Shiva Sale
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA
| | - Andra E. Duncan
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA
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21
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van Schie MS, Veen D, Kharbanda RK, Heida A, Starreveld R, van Schaagen FRN, Bogers AJJC, Taverne YJHJ, de Groot NMS. Characterization of pre-existing arrhythmogenic substrate associated with de novo early and late postoperative atrial fibrillation. Int J Cardiol 2022; 363:71-79. [PMID: 35705170 DOI: 10.1016/j.ijcard.2022.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/01/2022] [Accepted: 06/10/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND PoAF is the most common complication after cardiac surgery and may occur in patients with pre-existing arrhythmogenic substrate. Characterization of this substrate could aid in identifying patients at risk for PoAF. We therefore compared intra-atrial conduction parameters and electrogram morphology between patients without and with early- (≤5 days after surgery) and late- (up to 5 years) postoperative atrial fibrillation (PoAF). METHODS AND RESULTS Epicardial mapping of the right and left atrium and Bachmann's Bundle (BB) was performed during sinus rhythm (SR) in 263 patients (207male, 67 ± 11 years). Unipolar potentials were classified as single, short or long double and fractionated potentials. Unipolar voltage, fractionation delay (time difference between the first and last deflection), conduction velocity (CV) and conduction block (CB) prevalence were measured. Comparing patients without (N = 166) and with PoAF (N = 97), PoAF was associated with lower CV and more CB at BB. Unipolar voltages were lower and more low-voltage areas were found at the left and right atrium and BB in PoAF patients. These differences were more pronounced in patients with late-PoAF (6%), which could even occur up to 5 years after surgery. Although several electrophysiological parameters were related to PoAF, age was the only independent predictor. CONCLUSIONS Patients with de novo PoAF have more extensive arrhythmogenic substrate prior to cardiac surgery compared to those who remained in SR, which is even more pronounced in late-PoAF patients. Future studies should evaluate whether intra-operative electrophysiological examination enables identification of patients at risk for developing PoAF and hence (preventive) therapy.
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Affiliation(s)
- Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Danny Veen
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Rohit K Kharbanda
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Annejet Heida
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Roeliene Starreveld
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Frank R N van Schaagen
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
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22
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Chapalain X, Oilleau JF, Henaff L, Lorillon PharmD P, Saout DL, Kha P, Pluchon K, Bezon E, Huet O. Short acting intravenous beta-blocker as a first line of treatment for atrial fibrillation after cardiac surgery: a prospective observational study. Eur Heart J Suppl 2022; 24:D34-D42. [PMID: 35706899 PMCID: PMC9190753 DOI: 10.1093/eurheartjsupp/suac025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Post-operative atrial fibrillation (POAF) defined as a new-onset of atrial fibrillation (AF) following surgery occurs frequently after cardiac surgery. For non-symptomatic patients, rate control strategy seems to be as effective as rhythm control one in surgical patients. Landiolol is a new highly cardio-selective beta-blocker agent with interesting pharmacological properties that may have some interest in this clinical situation. This is a prospective, monocentric, observational study. All consecutive adult patients (age >18 years old) admitted in the intensive care unit following cardiac surgery with a diagnosed episode of AF were eligible. Success of landiolol administration was defined by a definitive rate control from the beginning of infusion to the 72th h. We also evaluated rhythm control following landiolol infusion. Safety analysis was focused on haemodynamic, renal and respiratory side effects. From 1 January 2020 to 30 June 2021, we included 54 consecutive patients. A sustainable rate control was obtained for 49 patients (90.7%). Median time until a sustainable rate control was 4 h (1, 22). Median infusion rate of landiolol needed for a sustainable rate control was 10 µg/kg/min (6, 19). Following landiolol infusion, median time until pharmacological cardioversion was 24 h. During landiolol infusion, maintenance of mean arterial pressure target requires a concomitant very low dose of norepinephrine. We did not find any other side effects. Low dose of landiolol used for POAF treatment was effective and safe for a rapid and sustainable rate and rhythm control after cardiac surgery.
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Affiliation(s)
- X Chapalain
- Department of Anesthesiology and Surgical intensive care unit, Brest University Hospital, 29200 Brest, France
| | - J F Oilleau
- Department of Anesthesiology and Surgical intensive care unit, Brest University Hospital, 29200 Brest, France
| | - L Henaff
- Department of Anesthesiology and Surgical intensive care unit, Brest University Hospital, 29200 Brest, France
| | - P Lorillon PharmD
- Department of Pharmacy, Brest University Hospital, 29200 Brest, France
| | - D Le Saout
- Department of Anesthesiology and Surgical intensive care unit, Brest University Hospital, 29200 Brest, France
| | - P Kha
- Department of Anesthesiology and Surgical intensive care unit, Brest University Hospital, 29200 Brest, France
| | - K Pluchon
- Department of Cardiovascular and Thoracic Surgery, Brest University Hospital, 29200 Brest, France
| | - E Bezon
- Department of Cardiovascular and Thoracic Surgery, Brest University Hospital, 29200 Brest, France
| | - O Huet
- Department of Anesthesiology and Surgical intensive care unit, Brest University Hospital, 29200 Brest, France
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23
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Tohme J, Sleilaty G, Jabbour K, Gergess A, Hayek G, Jebara V, Madi-Jebara S. Preoperative Oral Magnesium loading to prevent postoperative Atrial Fibrillation following Coronary Surgery (POMAF-CS): A prospective randomized controlled trial. Eur J Cardiothorac Surg 2022; 62:6572346. [PMID: 35451469 DOI: 10.1093/ejcts/ezac269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/15/2022] [Accepted: 04/19/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Postoperative atrial fibrillation is common following coronary artery bypass grafting surgery. Hypomagnesemia is frequent after coronary artery bypass grafting surgery. No previous trials have assessed the effect of preoperative magnesium loading on postoperative atrial fibrillation incidence. METHODS Design: This was a single-center, double-blind, placebo-controlled, parallel-group trial, with balanced randomization [1:1]. Participants: were recruited from November 2018 until May 2019. Patients received either 3.2 g of magnesium daily (4 tablets of 0.4 g each twice daily) for 72 hours preoperatively and 1.6 g of magnesium (4 tablets) on the day of surgery, or placebo tablets. RESULTS The primary outcome was the incidence of postoperative atrial fibrillation. Secondary outcomes included time to extubation, transfusion rate, critical care unit and hospital length of stay. Of the 210 randomized participants, 200 (100 in each group) completed the study. 10 (10%) and 22(22%) subjects developed postoperative atrial fibrillation in the magnesium and placebo groups, respectively (RR = 0.45, 95% CI: 0.23 - 0.91). Hospital and critical care unit length of stay were comparable between the 2 groups. No side effect related to magnesium administration were documented. CONCLUSION In this randomized controlled trial, preoperative loading with oral administration of magnesium for 3 days in patients admitted for coronary artery bypass grafting surgery decreases the incidence of postoperative atrial fibrillation compared to placebo (NCT03703349). CLINICAL TRIAL REGISTRY NUMBER NCT03703349.
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Affiliation(s)
- Joanna Tohme
- Department of anesthesia and critical care, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon
| | - Ghassan Sleilaty
- Department of cardiovascular and thoracic surgery, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon.,Clinical Research Center, Faculty of Medicine, Université Saint-Joseph, Beirut, Lebanon
| | - Khalil Jabbour
- Department of anesthesia and critical care, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon
| | - Afrida Gergess
- Department of anesthesia and critical care, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon
| | - Gemma Hayek
- Department of anesthesia and critical care, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon
| | - Victor Jebara
- Department of cardiovascular and thoracic surgery, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon
| | - Samia Madi-Jebara
- Department of anesthesia and critical care, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon
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24
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Mork C, Amacher SA, Gahl B, Koechlin L, Miazza J, Schaeffer T, Schmuelling L, Bremerich J, Berdajs D, Cueni N, Kühne M, Mueller C, Osswald S, Reuthebuch O, Schurr U, Sticherling C, Kopp Lugli A, Marsch S, Pargger H, Siegemund M, Eckstein F, Hollinger A, Santer D. Non-invasive evaluation of new-onset atrial fibrillation after cardiac surgery: a protocol for the BigMap study. ESC Heart Fail 2022; 9:2703-2712. [PMID: 35438261 PMCID: PMC9288739 DOI: 10.1002/ehf2.13902] [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] [Received: 09/05/2021] [Revised: 01/30/2022] [Accepted: 03/09/2022] [Indexed: 11/25/2022] Open
Abstract
Aims New‐onset atrial fibrillation (NOAF) is the most common complication after cardiac surgery, occurring in 25–50% of patients. It is associated with post‐operative stroke, increased mortality, prolonged hospital length of stay, and higher treatment costs. Previous small observational studies have identified the left atrium as a source of the electrical rotors and foci maintaining NOAF, but confirmation by a large prospective clinical study is still missing. The aim of the proposed study is to investigate whether the source of NOAF lies in the left atrium. The correct identification of NOAF‐maintaining structures in cardiac surgical patients might offer potential therapeutic targets for prophylactic perioperative ablation strategies. Methods and results This is a prospective single‐centre observational study of patients developing NOAF after cardiac surgery. The primary outcome is the description of NOAF‐maintaining structures within the atria. Key secondary outcomes include overall mortality, intensive care unit length of stay, hospital–ventilator‐free days, and proportion of persistent NOAF. In NOAF patients, the non‐invasive electrophysiological mapping will be conducted using a 252‐electrode electrocardiogram vest. After mapping, a low‐dose computed tomography scan of the chest will be performed to integrate the electrophysiological mapping results into a 3D picture of the heart. The study will include approximately 570 patients, of whom 30% (n = 170) are expected to develop NOAF. Sample size calculation revealed that 157 NOAF patients are necessary to assess the primary outcome. Patients will be tracked for a total of 5 years. Conclusions This is the largest prospective study to date describing the electrophysiological mechanisms of NOAF using non‐invasive mapping.
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Affiliation(s)
- Constantin Mork
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland.,Cardiovascular Research Institute (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - Brigitta Gahl
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
| | - Luca Koechlin
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland.,Cardiovascular Research Institute (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jules Miazza
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
| | - Thibault Schaeffer
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
| | - Lena Schmuelling
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Jens Bremerich
- Department of Radiology, University Hospital Basel, Basel, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Denis Berdajs
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Nadine Cueni
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Michael Kühne
- Cardiovascular Research Institute (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Stefan Osswald
- Cardiovascular Research Institute (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Oliver Reuthebuch
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Ulrich Schurr
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
| | - Christian Sticherling
- Cardiovascular Research Institute (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Andrea Kopp Lugli
- Medical Faculty of the University of Basel, Basel, Switzerland.,Intermediate Care Unit, University Hospital Basel, Basel, Switzerland
| | - Stephan Marsch
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Hans Pargger
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Martin Siegemund
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland.,Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Friedrich Eckstein
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Alexa Hollinger
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - David Santer
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
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25
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Farahani AV, Omran AS, Abbasi K, Gholamrezaei A, Mansouri P, Tafti SHA, Jahangiri M. Perioperative Cardiac Troponin T and Risk of Postoperative Atrial Fibrillation in Coronary Artery Bypass Graft Surgery. Crit Pathw Cardiol 2022; 21:36-41. [PMID: 34919067 DOI: 10.1097/hpc.0000000000000276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Postoperative atrial fibrillation (AF) is a common complication after cardiac surgery. We investigated whether perioperative cardiac troponin T (cTnT) is associated with the risk of AF after coronary artery bypass grafting (CABG). METHODS Two thousand four hundred twenty-one patients with isolated CABG were studied. High sensitivity cTnT (hs-cTnT) was assessed before and then at 80 hour and 24 hour after the operation. Logistic regression models were applied to investigate the association of perioperative hs-cTnT with postoperative AF. The ROC curve analysis was applied to determine the optimal cutoff values. RESULTS Postoperative AF was occurred in 356 (14.7%) patients. Age (adjusted odds ratio [ORs] 1.087-1.090), male gender (OR 1.390), left atrium size (ORs 1.055-1.111), on-pump coronary bypass (OR 1.561), and application of intra-aortic balloon pump (ORs 2.890-2.966) were independently associated with AF. Preoperative hs-cTnT was associated with AF in patients with off-pump coronary bypass (ORs 1.997-2.375). However, the area under the curve for preoperative hs-cTnT was 0.625 in this group. On-pump coronary bypass had major influence on postoperative hs-cTnT levels regardless of the occurrence of AF. CONCLUSIONS Preoperative hs-cTnT level is associated with the risk of AF after isolated CABG in patients undergoing off-pump coronary bypass, but the accuracy of this biomarker is yet inadequate. Postoperative levels of hs-cTnT have no predictive value considering large influence by the surgical technique and the cardiac surgery itself. Therefore, perioperative hs-cTnT is not a clinically useful biomarker for predicting AF following CABG.
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Affiliation(s)
- Ali Vasheghani Farahani
- From the Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Cardiology, School of Medicine, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbas Salehi Omran
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Kyomars Abbasi
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Gholamrezaei
- Department of Chronic Diseases, Metabolism and Ageing, University of Leuven, Leuven, Belgium
| | - Pejman Mansouri
- From the Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Cardiology, School of Medicine, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mansour Jahangiri
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
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26
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Xin L, Chenghao C, Shuwen H, Shenglin G, Chengxin Z. Association of red blood cell distribution width with postoperative new-onset atrial fibrillation following cardiac valve replacement surgery: A retrospective study. Biomarkers 2022; 27:286-292. [PMID: 35137658 DOI: 10.1080/1354750x.2022.2040590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE The aim of this study was to evaluate the impact of preoperative red blood cell distribution width (RDW) values on the risk of postoperative new-onset atrial fibrillation (PNAF) during hospitalization following cardiac valve replacement surgery. MATERIALS AND METHODS The clinical data of 148 patients with preoperative sinus rhythm who underwent cardiac valve replacement surgery at The First Affiliated Hospital of Anhui Medical University from September 2017 to June 2018 were retrospectively analyzed. Univariate and multivariate logistic regression analyses were used to determine the relationship between preoperative RDW values and the development of PNAF. RESULTS Forty-nine of the 148 patients (33.1%) developed PNAF. The median preoperative RDW was 13.1 (12.6-17.2), while the median RDW value was significantly higher in patients with PNAF than in those without PNAF [14.1 (13.2-15.0) vs. 12.9 (12.4-13.5), P < 0.001]. Multivariate logistic regression analysis showed that preoperative RDW values were significantly correlated with the occurrence of PNAF (odds ratio: 1.940, 95% confidence interval: 1.377 to 2.731, P < 0.001). CONCLUSIONS Preoperative RDW is an independent risk factor for PNAF during hospitalization following cardiac valve replacement surgery. This finding suggests that preoperative RDW measurement may be used to stratify the risk for PNAF development in patients undergoing cardiac surgery.
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Affiliation(s)
- Li Xin
- Department of Cardiovascular surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Chu Chenghao
- Department of Cardiovascular surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Hou Shuwen
- Department of Cardiovascular surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Ge Shenglin
- Department of Cardiovascular surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Zhang Chengxin
- Department of Cardiovascular surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
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27
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Brochu D, St-Arnaud A, Marchand LÉ, Voisine P, Méthot J. Impact of COVID-19 on the Prescribing Pattern of Oral Anticoagulants for Atrial Fibrillation After Cardiac Surgery. J Cardiovasc Pharmacol Ther 2022; 27:10742484221128124. [PMID: 36189934 DOI: 10.1177/10742484221128124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Because of logistic challenges associated with the COVID-19 pandemic, direct oral anticoagulants (DOAC) were favored over warfarin in patients presenting postoperative atrial fibrillation (AF) after cardiac surgery in our institution. Considering the limited evidence supporting the use of DOAC in this context, we sought to evaluate the safety and efficacy of this practice change. METHODS A retrospective study was performed with patients from the Quebec City metropolitan area who were hospitalized at the Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval following cardiac surgery and who required oral anticoagulant (OAC) for postoperative AF. The primary objective was to compare the pre- and peri-COVID-19 period for OAC prescribing patterns and the incidence of thrombotic and bleeding events at 3 months post-surgery. The secondary objective was to compare DOAC to warfarin in terms of thrombotic events and bleeding events. RESULTS A total of 233 patients were included, 142 from the pre-COVID-19 and 91 from the peri-COVID-19 period, respectively. Both groups had equivalent proportions of preoperative AF (48%) and new-onset postoperative AF (52%). The proportion of patients treated with a DOAC increased from 13% pre-COVID-19 to 82% peri-COVID-19. This change in practice was not associated with a significant difference in the incidence of thrombotic or bleeding events 3 months postoperatively. However, compared to DOAC, warfarin was associated with a higher incidence of major bleeding. Only 1 thrombotic event was reported with warfarin, and none were reported with DOAC. CONCLUSION This study suggests that DOAC are an effective and safe alternative to warfarin to treat postoperative AF after cardiac surgery and that this practice can be safely maintained.
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Affiliation(s)
- Dannick Brochu
- Faculty of Pharmacy, 4440Université Laval, Quebec City, Québec, Canada
- 55973Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Quebec City, Québec, Canada
| | - Amélie St-Arnaud
- Faculty of Pharmacy, 4440Université Laval, Quebec City, Québec, Canada
- 55973Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Quebec City, Québec, Canada
| | - Louis-Étienne Marchand
- Faculty of Pharmacy, 4440Université Laval, Quebec City, Québec, Canada
- 55973Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Quebec City, Québec, Canada
| | - Pierre Voisine
- 55973Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Quebec City, Québec, Canada
- Faculty of Medicine, 4440Université Laval, Quebec City, Québec, Canada
| | - Julie Méthot
- Faculty of Pharmacy, 4440Université Laval, Quebec City, Québec, Canada
- 55973Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Quebec City, Québec, Canada
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28
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Lee S, Vitebskiy S, Goldstein RN, Khrestian CM, Waldo AL. Reliable pace termination of postoperative atrial fibrillation in the canine sterile pericarditis model: Implications for atypical atrial flutter. Heart Rhythm O2 2022; 3:91-96. [PMID: 35243440 PMCID: PMC8859807 DOI: 10.1016/j.hroo.2022.01.003] [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] [Indexed: 11/03/2022] Open
Abstract
Background We have identified a reentrant circuit in the pulmonary vein region, which drives the atria, producing fibrillatory conduction, as one mechanism of postoperative atrial fibrillation (POAF) in the canine sterile pericarditis model. Objective In this model, we tested the hypothesis that overdrive pacing from a site at or near such a reentrant circuit would interrupt it and thereby terminate POAF. Methods We studied 11 sterile pericarditis dogs on postoperative days 1–4. Atrial electrograms (AEGs) were recorded during POAF, overdrive pacing, and pace termination from 3 sites simultaneously: Bachmann's bundle, posterior left atrium, and right atrial appendage. When recorded AEGs demonstrated regular activation, pace termination was attempted at that site by delivering a drive train starting with 4 consecutive beats at a cycle length (CL) of 2–5 ms shorter than that of the intrinsic CL. Results Sixteen episodes of sustained POAF (>5 minutes) diagnosed by electrocardiogram were induced. During all episodes of POAF, AEGs recorded from the left atrium exhibited regular activation, ie, constant AEG morphology and CL. When capture of the reentrant circuit by overdrive pacing occurred (mean 13 ± 5, range 5–23 beats), all 16 POAF episodes were successfully terminated. In all termination episodes, at the end of pacing but prior to the return of sinus rhythm, there was disorganized atrial activation in the previously organized sites (mean 2 seconds, range 0.1–8 seconds). However, these beats did not sustain POAF in the absence of a reentrant circuit (“driver”). Conclusion Overdrive pacing from a site demonstrating regular activation during sustained POAF terminated the POAF by interrupting the reentrant circuit.
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29
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Song P, Holmes M, Mackensen GB. Cardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00031-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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30
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Ofoegbu CKP, Manganyi RM. Off-Pump Coronary Artery Bypass Grafting; is it Still Relevant? Curr Cardiol Rev 2022; 18:e271021197431. [PMID: 34711166 PMCID: PMC9413736 DOI: 10.2174/1573403x17666211027141043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 06/22/2021] [Accepted: 07/29/2021] [Indexed: 11/22/2022] Open
Abstract
Off-pump Coronary Artery Bypass Grafting (OPCAB) experienced a resurgence in the 1980s -2000s and developed steadily with improvement of the instrumentation and techniques. However questions about graft patency and long-term survival of OPCAB patients still exist. This review attempts to explore the current relevance of OPCAB.
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Affiliation(s)
- Chima K P Ofoegbu
- Chris Barnard Division of Cardiothoracic Surgery, Groote Schuur Hospital Cape Town, Cape Town 7925, South Africa
| | - Rodgers M Manganyi
- Chris Barnard Division of Cardiothoracic Surgery, Groote Schuur Hospital Cape Town, Cape Town 7925, South Africa
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31
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Wang MK, Meyre PB, Heo R, Devereaux P, Birchenough L, Whitlock R, McIntyre WF, Peter Chen YC, Ali MZ, Biancari F, Butt JH, Healey JS, Belley-Côté EP, Lamy A, Conen D. Short-term and Long-term Risk of Stroke in Patients With Perioperative Atrial Fibrillation After Cardiac Surgery: Systematic Review and Meta-analysis. CJC Open 2022; 4:85-96. [PMID: 35072031 PMCID: PMC8767142 DOI: 10.1016/j.cjco.2021.09.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 09/12/2021] [Indexed: 11/24/2022] Open
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32
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Rajput HAS, Khan F, Zargar UQ, Iqbal F, Shamim K, Wahab A, Khalid I, Siddiqui Z, Rajput LS, Abbas K. Association of Atrial Fibrillation With Patient Characteristics in Postoperative Coronary Artery Bypass Grafting Surgery. Cureus 2021; 13:e19800. [PMID: 34956788 PMCID: PMC8693829 DOI: 10.7759/cureus.19800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction Atrial fibrillation (AF) after coronary artery bypass grafting (CABG) is correlated with poor patient outcomes. The study evaluated the association of patients' clinical and sociodemographic characteristics with the incidence of atrial fibrillation, postoperatively. Methodology A longitudinal study was performed in the cardiology department of a tertiary care unit, Sindh, Pakistan between October 2019 and November 2020. All patients who underwent CABG surgery irrespective of gender aged 30 to 75 years were included in the study. Patients with a history of atrial fibrillation or severe left ventricular dysfunction were excluded from the study. The incidence of atrial fibrillation was determined by observing an irregular pattern on electrocardiography (ECG) with no definite P-wave and irregular R-R interval. The patients were monitored for seven postoperative days. The final outcome was measured on the seventh postoperative day. Results A total of 247 patients with a mean age of 63.43 ± 9.72 were enrolled in the study. Out of the 247 patients, 9.7% developed new-onset atrial fibrillation, postoperatively. Age above 65 years was associated with the occurrence of AF but it was not statistically significant (p>0.05). Similarly, patients who developed AF were more likely to have a left ventricle ejection fraction (LVEF) of less than 35% than those without AF (66.67% vs 43.95%; p=0.033). Conclusion A high rate of AF was observed in the study. Older age and impaired ventricular function were significantly associated with atrial fibrillation. It is recommended that hospitals should devise guidelines and protocols for the prevention and management of atrial fibrillation in patients undergoing cardiothoracic surgeries in order to minimize patient mortality and improve patient outcomes.
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Affiliation(s)
| | - Faryal Khan
- Department of Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Uzair Qayum Zargar
- Department of Medicine, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Fizza Iqbal
- Department of Medicine, Dow Medical College, Karachi, PAK
| | - Khizer Shamim
- Department of Medicine, Ziauddin University, Karachi, PAK
| | - Abdul Wahab
- Department of Medicine, Abbasi Shaheed Hospital, Karachi, PAK
| | - Izza Khalid
- Department of Medicine, Fatima Jinnah Medical University, Lahore, PAK
| | - Zainab Siddiqui
- Department of Medicine, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Laraib S Rajput
- Department of Medicine, Dow University Hospital, Karachi, PAK
| | - Kiran Abbas
- Department of Medicine, Jinnah Postgraduate Medical Centre, Karachi, PAK
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33
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Riad FS, German K, Deitz S, Sahadevan J, Sundaram V, Waldo AL. Contemporary Anticoagulation Practices for Postoperative Atrial Fibrillation: A Single Center Experience. J Atr Fibrillation 2021; 13:2443. [PMID: 34950327 DOI: 10.4022/jafib.2443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/11/2020] [Accepted: 10/12/2020] [Indexed: 11/10/2022]
Abstract
Aims Postoperative atrial fibrillation (POAF) is a frequent in-hospital complication after cardiac surgery. Surprisingly, despite its prevalence, management of this condition has not been well studied. One promising approach that has been evaluated in a limited number of studies is use of anticoagulation. However, the trends and patterns of real-world use of anticoagulation in POAF patients has not been systemically investigated. In this study, we aimed to determine real-world patterns of anticoagulation use for patients with POAF. Methods We identified 200 patients undergoing coronary artery bypass (CABG) or cardiac valve surgery at University Hospitals Cleveland Medical Center over a 2 year period beginning January 2016 with new onset POAF. We reviewed charts to verify candidacy for inclusion in the study and to extract data on anticoagulation use, adverse outcomes, and CHA2DS2-VASc scores. Results Anticoagulation use was low after CABG, but high after bioprosthetic valve surgery. The most common anticoagulant used was warfarin. Anticoagulation use was not correlated with CHA2DS2-VASc score or cardioversion. Stroke and mortality were higher among patients not receiving anticoagulation, however, confirmation of this finding in larger randomized studies is warranted. Conclusions Anticoagulation use is low after CABG and this practice does not appear to be affected by CHA2DS2VASc score or cardioversion. This differs with previously reported provider attitudes towards management of this condition. Stroke and mortality appear to be elevated for patients not receiving anticoagulation but further investigation is required to confirm this observation.
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Affiliation(s)
- Fady S Riad
- aHarrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University, Cleveland, OH
| | - Konstantin German
- aHarrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University, Cleveland, OH
| | - Sarah Deitz
- aHarrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University, Cleveland, OH
| | - Jayakumar Sahadevan
- aHarrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University, Cleveland, OH.,Department of Medicine, Louis Stokes Veteran Affairs Medical Center, Cleveland, Ohio
| | - Varun Sundaram
- aHarrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University, Cleveland, OH
| | - Albert L Waldo
- aHarrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University, Cleveland, OH
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34
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Selcuk M, Cinar T, Saylik F, Dogan S, Selcuk I, Orhan AL. Predictive Value of Systemic Immune Inflammation Index for Postoperative Atrial Fibrillation in Patients Undergoing Isolated Coronary Artery Bypass Grafting. Medeni Med J 2021; 36:318-324. [PMID: 34939398 PMCID: PMC8694166 DOI: 10.4274/mmj.galenos.2021.37998] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective: Inflammation plays an important role in the initiation of postoperative atrial fibrillation (PoAF) in individuals undergoing cardiac surgery, Thus, this study aimed to investigate the predictive value of the systemic immune inflammation index (SII) to develop PoAF in such patients. Methods: In total, 391 consecutive patients undergoing an isolated coronary artery bypass grafting (CABG) were retrospectively analyzed. PoAF was defined according to the current guideline. The SII is determined using the following equation: neutrophil (N) × platelet (P) ÷ lymphocyte (L). Results: The incidence of PoAF in the present study was 24% (n=97 cases). Multivariate logistic regression analysis revealed that the SII was an independent predictor of PoAF (Odds ratio: 1.002 95% confidence interval: (1.001-1.002), p<0.01). The optimal value of the SII in detecting PoAF was established by a receiver operating characteristic curve assessment, and it was >807.8 with 60.8% sensitivity and 80.9% specificity [area under the curve (AUC): 0.7107]. The AUC value of SII in detecting PoAF was much greater than the AUC values of both the neutrophil to lymphocyte ratio (NLR) and the platelet to lymphocyte ratio (PLR) (AUC: 0.6740 and AUC: 0.6426, respectively). Conclusions: This study revealed that SII was an independent predictor of PoAF in patients who were operated on for isolated CABG. Additionally, SII had a better discriminative ability for PoAF compared to either NLR or PLR among these cases.
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Affiliation(s)
- Murat Selcuk
- University of Health Sciences Turkey, Istanbul Sultan 2. Abdulhamid Han Training and Research Hospital, Clinic of Cardiology, Istanbul, Turkey
| | - Tufan Cinar
- University of Health Sciences Turkey, Istanbul Sultan 2. Abdulhamid Han Training and Research Hospital, Clinic of Cardiology, Istanbul, Turkey
| | - Faysal Saylik
- University of Health Sciences Turkey, Van Training and Research Hospital, Turkey, Clinic of Cardiology, Van, Turkey
| | - Selami Dogan
- University of Health Sciences Turkey, Istanbul Sultan 2. Abdulhamid Han Training and Research Hospital, Clinic of Cardiology, Istanbul, Turkey
| | - Ismail Selcuk
- University of Health Sciences Turkey, Istanbul Sultan 2. Sultan Abdulhamid Training and Research Hospital, Clinic of Cardiovascular Surgery, Istanbul, Turkey
| | - Ahmet L Orhan
- University of Health Sciences Turkey, Istanbul Sultan 2. Abdulhamid Han Training and Research Hospital, Clinic of Cardiology, Istanbul, Turkey
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35
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Neves IA, Magalhães A, Lima da Silva G, Almeida AG, Borges M, Costa J, Ferreira JJ, Pinto FJ, Caldeira D. Anticoagulation therapy in patients with post-operative atrial fibrillation: Systematic review with meta-analysis. Vascul Pharmacol 2021; 142:106929. [PMID: 34757209 DOI: 10.1016/j.vph.2021.106929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/10/2021] [Accepted: 10/19/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Post-operative atrial fibrillation (POAF) is a relevant complication after surgery. Several studies have shown that POAF has important consequences for long-term morbidity and mortality, by increasing the risk of thromboembolic events. However, the use of oral anticoagulation (OAC) is not well established in this context. METHODS We searched MEDLINE, CENTRAL, PsycInfo and Web of Science for clinical trials and observational studies evaluating anticoagulation vs. no anticoagulation in patients with POAF (after cardiac or non-cardiac surgery). Data were screened and extracted by two independent reviewers. We performed a random- effects model to estimate the pooled odds ratio (OR) with 95% Confidence Intervals (CI), and heterogeneity was evaluated by I2 statistics. The outcomes of interest were all-cause mortality, thromboembolic events, and bleeding events. RESULTS Overall, 10 observational retrospective studies were included: 5 studies with 203,946 cardiac surgery POAF patients, and 5 studies with 29,566 patients with POAF after non-cardiac surgery. In cardiac surgery POAF, the OAC use was associated with lower risk of thromboembolic events (OR 0.68; 95%CI 0.47-0.96, I2 = 31%; 4 studies) and the bleeding risk was significantly increased (OR 4.30; 95%CI 3.69 to 5.02, 1 study). In non-cardiac surgery POAF, OAC did not significantly reduce the risk of thromboembolic events (OR 0.71, 95%CI 0.33-1.15; I2 = 79%; 5 studies) but was associated with increased risk of bleeding (OR 1.20, 95%CI 1.10-1.32, I2 = 0%; 3 studies). Mortality was not significantly reduced in both cardiac and non-cardiac surgery POAF. CONCLUSION Oral anticoagulation was associated with a lower risk of thromboembolic events in patients with POAF following cardiac surgery but not in non-cardiac surgery. Bleeding risk was increased in both settings. The confidence on pooled results is at most low, and further data, namely randomized controlled trials are necessary to derive robust conclusions.
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Affiliation(s)
| | - Andreia Magalhães
- Centro Cardiovascular da Universidade de Lisboa, CAML, Faculdade de Medicina da Universidade de Lisboa, Portugal; Cardiology Department, Hospital Santa Maria - Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisbon, Portugal
| | - Gustavo Lima da Silva
- Centro Cardiovascular da Universidade de Lisboa, CAML, Faculdade de Medicina da Universidade de Lisboa, Portugal; Cardiology Department, Hospital Santa Maria - Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisbon, Portugal
| | - Ana G Almeida
- Centro Cardiovascular da Universidade de Lisboa, CAML, Faculdade de Medicina da Universidade de Lisboa, Portugal; Cardiology Department, Hospital Santa Maria - Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisbon, Portugal
| | - Margarida Borges
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Universidade de Lisboa, Lisbon, Portugal; Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - João Costa
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Universidade de Lisboa, Lisbon, Portugal; Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - Joaquim J Ferreira
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Universidade de Lisboa, Lisbon, Portugal; Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Portugal; CNS - Neurological Senior Campus, Torres Vedras, Portugal
| | - Fausto J Pinto
- Centro Cardiovascular da Universidade de Lisboa, CAML, Faculdade de Medicina da Universidade de Lisboa, Portugal; Cardiology Department, Hospital Santa Maria - Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisbon, Portugal
| | - Daniel Caldeira
- Centro Cardiovascular da Universidade de Lisboa, CAML, Faculdade de Medicina da Universidade de Lisboa, Portugal; Cardiology Department, Hospital Santa Maria - Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisbon, Portugal; Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Universidade de Lisboa, Lisbon, Portugal.
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Abstract
Atrial fibrillation occurs in 5-40% patients after coronary artery bypass graft surgery. Atrial fibrillation increases mortality and morbidity in the post-operative period. We sought to conduct a comprehensive review of literature focusing on pathophysiology, risk factors, prevention and treatment of post coronary artery bypass graft atrial fibrillation.
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Affiliation(s)
- Ashraf Mostafa
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
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37
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Demal TJ, Fehr S, Mariscalco G, Reiter B, Bibiza E, Reichenspurner H, Gatti G, Onorati F, Faggian G, Salsano A, Santini F, Perrotti A, Santarpino G, Zanobini M, Saccocci M, Musumeci F, Rubino AS, De Feo M, Bancone C, Nicolini F, Dalén M, Maselli D, Bounader K, Mäkikallio T, Juvonen T, Ruggieri VG, Biancari F. Coronary Artery Bypass Grafting in Patients With High Risk of Bleeding. Heart Lung Circ 2021; 31:263-271. [PMID: 34330630 DOI: 10.1016/j.hlc.2021.06.519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/31/2021] [Accepted: 06/08/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Postoperative bleeding after cardiac surgery is associated with increased morbidity and mortality. We tested the hypothesis that patients with a preoperatively estimated high risk of severe perioperative bleeding may have impaired early outcome after on-pump versus off-pump coronary artery bypass grafting (CABG). METHOD Data from 7,352 consecutive patients who underwent isolated CABG from January 2015 to May 2017 were included in the multicentre European Coronary Artery Bypass Grafting registry. The postoperative bleeding risk was estimated using the WILL-BLEED risk score. Of all included patients, 3,548 had an increased risk of severe perioperative bleeding (defined as a WILL-BLEED score ≥4) and were the subjects of this analysis. We compared the early outcomes between patients who underwent on-pump or off-pump CABG using a multivariate mixed model for risk-adjusted analysis. RESULTS Off-pump surgery was performed in 721 patients (20.3%). On-pump patients received more packed red blood cell units (on-pump: 1.41 [95% confidence interval {CI}, 0.99-1.86]; off-pump: 0.86 [95% CI, 0.64-1.08]; p<0.001), had a longer stay in the intensive care unit (on-pump: 4.4 [95% CI, 3.6-8.1] days; off-pump: 3.2 [95% CI, 2.0-4.4] days; p=0.049), and a higher rate of postoperative atrial fibrillation (on-pump: 46.5% [95% CI, 34.9-58.1]; off-pump: 31.3% [95% CI, 21.7-40.9]; p=0.025). Furthermore, on-pump patients showed a trend towards a higher rate of postoperative stroke (on-pump: 2.4% [95% CI, 0.9-4.1]; off-pump: 1.1 [95% CI 0.2-2.7]; p=0.094). CONCLUSION Our data suggest that in patients with an increased risk of bleeding, the use of cardiopulmonary bypass is associated with higher morbidity. These patients may benefit from off-pump surgery if complete revascularisation can be ensured.
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Affiliation(s)
- Till J Demal
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany.
| | - Samira Fehr
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany; Medical Clinic, Israelite Hospital Hamburg, Hamburg, Germany
| | - Giovanni Mariscalco
- Department of Cardiac Surgery, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK
| | - Beate Reiter
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Eric Bibiza
- Department of Medical Biometry and Epidemiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Cardiothoracic and Vascular Department, Trieste University Hospital, Trieste, Italy
| | - Francesco Onorati
- Department of Cardiac Surgery, Verona University Hospital, Verona, Italy
| | - Giuseppe Faggian
- Department of Cardiac Surgery, Verona University Hospital, Verona, Italy
| | - Antonio Salsano
- Division of Cardiac Surgery, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Francesco Santini
- Division of Cardiac Surgery, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Andrea Perrotti
- Department of Thoracic and Cardiovascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Giuseppe Santarpino
- Department of Clinical and Experimental Medicine, Magna Graecia University, Catanzaro, Italy; Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy; Department of Cardiac Surgery, Klinikum Nu¨rnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Marco Zanobini
- Department of Cardiac Surgery, Centro Cardiologico - Fondazione Monzino IRCCS, Milan, Italy
| | - Matteo Saccocci
- Department of Cardiac Surgery, Centro Cardiologico - Fondazione Monzino IRCCS, Milan, Italy
| | - Francesco Musumeci
- Unit of Cardiac Surgery, Department of Cardiosciences, Hospital S. Camillo-Forlanini, Rome, Italy
| | - Antonino S Rubino
- Cardiac Surgery Unit, Ferrarotto Hospital, University of Catania, Catania, Italy; Department of Cardiothoracic Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Marisa De Feo
- Department of Cardiothoracic Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Ciro Bancone
- Department of Cardiothoracic Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Magnus Dalén
- Department of Molecular Medicine and Surgery, and Department of Cardiothoracic Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Daniele Maselli
- Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Timo Mäkikallio
- Division of Cardiology, Department of Internal Medicine, University Hospital of Oulu, Oulu, Finland
| | - Tatu Juvonen
- Research Unit of Surgery, Anesthesiology and Critical Care, University of Oulu, Oulu, Finland; Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Vito G Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, France
| | - Fausto Biancari
- Research Unit of Surgery, Anesthesiology and Critical Care, University of Oulu, Oulu, Finland; Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland; Department of Surgery, University of Turku, Turku, Finland
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Liu M, Mei K, Xie L, Ma J, Yu P, Niu S, Xu Y, Zhao Y, Liu X. Dose-response relationship among body mass index, abdominal adiposity and atrial fibrillation in patients undergoing cardiac surgery: a meta-analysis of 35 cohorts. PeerJ 2021; 9:e11855. [PMID: 34327066 PMCID: PMC8308618 DOI: 10.7717/peerj.11855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 07/04/2021] [Indexed: 11/20/2022] Open
Abstract
Background Whether overweight increases the risk of postoperative atrial fibrillation (POAF) is unclear, and whether adiposity independently contributes to POAF has not been comprehensively studied. Thus, we conducted a meta-analysis to clarify the strength and shape of the exposure-effect relationship between adiposity and POAF. Methods The PubMed, Cochrane Library, and EMBASE databases were searched for revelant studies (randomized controlled trials (RCTs), cohort studies, and nest-case control studies) reporting data regarding the relationship between adiposity and the risk of POAF. Results Thirty-five publications involving 33,271 cases/141,442 patients were included. Analysis of categorical variables showed that obesity (RR: 1.39, 95% CI [1.21–1.61]; P < 0.001), but not being underweight (RR: 1.44, 95% CI [0.90–2.30]; P = 0.13) or being overweight (RR: 1.03, 95% CI [0.95–1.11]; P = 0.48) was associated with an increased risk of POAF. In the exposure-effect analysis (BMI) was 1.09 (95% CI [1.05–1.12]; P < 0.001) for the risk of POAF. There was a significant linear relationship between BMI and POAF (Pnonlinearity = 0.44); the curve was flat and began to rise steeply at a BMI of approximately 30. Notably, BMI levels below 30 (overweight) were not associated with a higher risk of POAF. Additionally, waist obesity or visceral adiposity index was associated with the risk of POAF. Conclusion Based on the current evidence, our findings showed that high body mass index or abdominal adiposity was independently associated with an increased risk of POAF, while underweight or overweight might not significantly increase the POAF risk.
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Affiliation(s)
- Menglu Liu
- Department of Cardiology, Seventh People's Hospital of Zhengzhou, Zhengzhou, Henan, China
| | - Kaibo Mei
- Anesthesiology Department,, the People's Hospital of Shanggrao, Shangrao, Jiangxi, China
| | - Lixia Xie
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jianyong Ma
- Department of Pharmacology and Systems Physiology, University of Cincinnati College of Medicine, Cincinnati, Oh, China
| | - Peng Yu
- Department of Endocrine, the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Siquan Niu
- Department of Cardiology, Seventh People's Hospital of Zhengzhou, Zhengzhou, Henan, China
| | - Ya Xu
- Department of Cardiology, Seventh People's Hospital of Zhengzhou, Zhengzhou, Henan, China
| | - Yujie Zhao
- Department of Cardiology, Seventh People's Hospital of Zhengzhou, Zhengzhou, Henan, China
| | - Xiao Liu
- Department of Cardiology, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Province Key Laboratory of Arrhythmia and Electrophysiology, Guangzhou, Guangdong, China.,Guangzhou Key Laboratory of Molecular Mechanism and Translation in Major Cardiovascular Disease, Guangzhou, China
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39
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Sipahi FN, Sugimura Y, Boeken U, Yilmaz E, Makimoto H, Lichtenberg A, Dalyanoĝlu H. Treatment of Postoperative New Onset Atrial Fibrillation with Repolarization Delaying Agents after Heart Surgery. Ann Thorac Cardiovasc Surg 2021; 27:395-402. [PMID: 34276001 PMCID: PMC8684844 DOI: 10.5761/atcs.oa.21-00070] [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: 11/16/2022] Open
Abstract
PURPOSE The aim of this study was to evaluate the efficacy of the multichannel-blocker dronedarone for postoperative new onset atrial fibrillation (POAF) as compared to amiodarone. METHODS Out of 990 patients who underwent cardiothoracic surgery between March 2011 and March 2012, 166 patients who developed POAF and treated with amiodarone or dronedarone were enrolled in this study. RESULTS Eighty-nine patients were treated with amiodarone and 77 patients were treated with dronedarone at discharge. Seventy-five percent of patients with dronedarone were treated initially with intravenous amiodarone but quickly converted to oral dronedarone as soon as the mechanical ventilation was weaned off. The rate of conversion in sinus rhythm was not influenced by the resulting amiodarone-to-dronedarone crossover as compared to oral dronedarone only (p <0.247 at the ICU and p <0.640 at the normal care unit). At hospital discharge sinus rhythm was documented in 44% of the amiodarone patients and 99% of the dronedarone patients (p <0.001). The maintenance of sinus rhythm was demonstrated in 82% of the amiodarone patients versus 81% of the dronedarone patients at 6-month follow-up (p <0.804). CONCLUSIONS Our data demonstrated the higher conversion rate to sinus rhythm in the early phase in the dronedarone group despite a comparable conversion rate in the mid-term phase compared to amiodarone.
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Affiliation(s)
- Firat Nihat Sipahi
- Department of Cardiac Surgery, Heinrich Heine University, Düsseldorf, Germany
| | - Yukiharu Sugimura
- Department of Cardiac Surgery, Heinrich Heine University, Düsseldorf, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Düsseldorf, Germany
| | - Esma Yilmaz
- Department of Cardiac Surgery, Heinrich Heine University, Düsseldorf, Germany
| | - Hisaki Makimoto
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Düsseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Heinrich Heine University, Düsseldorf, Germany
| | - Hannan Dalyanoĝlu
- Department of Cardiac Surgery, Heinrich Heine University, Düsseldorf, Germany
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40
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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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41
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Kiviniemi T, Bustamante-Munguira J, Olsson C, Jeppsson A, Halfwerk FR, Hartikainen J, Suwalski P, Zindovic I, Copa GR, van Schaagen FRN, Hanke T, Cebotari S, Malmberg M, Fernandez-Gutierrez M, Bjurbom M, Schersten H, Speekenbrink R, Riekkinen T, Ek D, Vasankari T, Lip GYH, Airaksinen KEJ, van Putte B. A randomized prospective multicenter trial for stroke prevention by prophylactic surgical closure of the left atrial appendage in patients undergoing bioprosthetic aortic valve surgery--LAA-CLOSURE trial protocol. Am Heart J 2021; 237:127-134. [PMID: 33798494 DOI: 10.1016/j.ahj.2021.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/24/2021] [Indexed: 11/17/2022]
Abstract
Patients undergoing surgical aortic valve replacement (SAVR) are at high risk for atrial fibrillation (AF) and stroke after surgery. There is an unmet clinical need to improve stroke prevention in this patient population. The LAA-CLOSURE trial aims to assess the efficacy and safety of prophylactic surgical closure of the left atrial appendage for stroke and cardiovascular death prevention in patients undergoing bioprosthetic SAVR. This randomized, open-label, prospective multicenter trial will enroll 1,040 patients at 13 European sites. The primary endpoint is a composite of cardiovascular mortality, stroke and systemic embolism at 5 years. Secondary endpoints include cardiovascular mortality, stroke, systemic embolism, bleed fulfilling academic research consortium (BARC) criteria, hospitalization for decompensated heart failure and health economic evaluation. Sample size is based on 30% risk reduction in time to event analysis of primary endpoint. Prespecified reports include 30-day safety analysis focusing on AF occurrence and short-term outcomes and interim analyses at 1 and 3 years for primary and secondary outcomes. Additionally, substudies will be performed on the completeness of the closure using transesophageal echocardiography/cardiac computed tomography and long-term ECG recording at one year after the operation.
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Affiliation(s)
- Tuomas Kiviniemi
- Turku University Hospital and University of Turku, Finland; Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | | | - Christian Olsson
- Karolinska University Hospital and The Karolinska Institutet, Stockholm, Sweden
| | - Anders Jeppsson
- Sahlgrenska University Hospital, Gothenburg, Sweden; and Department of Molecular and Clinical Medicine, Institute of Medicine. Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Frank R Halfwerk
- Medisch Spectrum Twente, Thoraxcentrum Twente, Enschede, The Netherlands
| | - Juha Hartikainen
- Kuopio University Hospital, and University of Eastern Finland, Kuopio, Finland
| | - Piotr Suwalski
- Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw, Warsaw, Poland
| | - Igor Zindovic
- Lund University, Skåne University Hospital, Department of Clinical Sciences, Lund, Department of Cardiothoracic Surgery, Lund, Sweden
| | | | | | | | | | | | | | - Markus Bjurbom
- Karolinska University Hospital and The Karolinska Institutet, Stockholm, Sweden
| | - Henrik Schersten
- Sahlgrenska University Hospital, Gothenburg, Sweden; and Department of Molecular and Clinical Medicine, Institute of Medicine. Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Ron Speekenbrink
- Medisch Spectrum Twente, Thoraxcentrum Twente, Enschede, The Netherlands
| | - Teemu Riekkinen
- Kuopio University Hospital, and University of Eastern Finland, Kuopio, Finland
| | - Danyal Ek
- Lund University, Skåne University Hospital, Department of Clinical Sciences, Lund, Department of Cardiothoracic Surgery, Lund, Sweden
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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42
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Khan JA, Laurikka JO, Järvinen OH, Khan NK, Järvelä KM. Early postoperative statin administration does not affect the rate of atrial fibrillation after cardiac surgery. Eur J Cardiothorac Surg 2021; 57:1154-1159. [PMID: 31930308 DOI: 10.1093/ejcts/ezz365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/19/2019] [Accepted: 12/09/2019] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Postoperative atrial fibrillation is the most frequent complication after cardiac surgery, and the use of statins in preventing them is being extensively studied. The aim of this study was to investigate whether a pause in the administration of statins affects the occurrence of atrial fibrillation after cardiac surgery in a prospective randomized and controlled setting. METHODS A total of 301 patients without chronic atrial fibrillation with prior statin medication scheduled for elective or urgent cardiac surgery involving the coronary arteries and/or heart valves were prospectively recruited and randomized for statin re-initiation on either the first (immediate statin group) or the fifth (late statin group) postoperative day, using the original medication and dosage. The immediate statin group comprised 146 patients and the late statin group 155 patients. Except for a somewhat higher rate of males (85% vs 73%, P = 0.016) in the immediate statin group, the baseline characteristics and the distribution of procedures performed within the groups were comparable. The occurrence of postoperative atrial fibrillation and the clinical course of the patients were compared between the groups. RESULTS The incidence of atrial fibrillation was 46% and the median delay after surgery before the onset of atrial fibrillation was 3 days in both groups (P = NS). No differences were observed in the frequency of the arrhythmia in any subgroup analyses or in other major complications or clinical parameters. No adverse effects related to early statin administration were detected. CONCLUSIONS Early re-initiation of statins does not appear to affect the occurrence of postoperative atrial fibrillation. CLINICAL TRIAL REGISTRATION European Union Drug Regulating Authorities Clinical Trials Database (EudraCT)-2016-001655-44.
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Affiliation(s)
- Jahangir A Khan
- Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - Jari O Laurikka
- Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Otto H Järvinen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Niina K Khan
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland
| | - Kati M Järvelä
- Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere University Hospital, Tampere, Finland
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43
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Wan Q, Li S, Hu J. Association of smoking with postoperative atrial fibrillation in patients with cardiac surgery: A PRISMA-compliant article. Medicine (Baltimore) 2021; 100:e26179. [PMID: 34115000 PMCID: PMC8202588 DOI: 10.1097/md.0000000000026179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/13/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Cigarette smoking is an important modifiable risk factor for incident atrial fibrillation. However, the impact of smoking on postoperative atrial fibrillation in patients undergoing cardiac surgery remains controversial. We performed this meta-analysis to explore the association of smoking with postoperative atrial fibrillation in patients with cardiac surgery. METHODS We systematically searched 2 computer-based databases (PubMed and EMBASE) up to July 2019 for all relevant studies. A random-effects model was selected to pool the odds ratios (ORs) and 95% confidence intervals (CIs). In this meta-analysis, the protocol and reporting of the results were based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. RESULTS A total of 36 studies were included in this meta-analysis. Overall, smoking was not associated with an increased risk of postoperative atrial fibrillation in patients undergoing cardiac surgery (odds ratio [OR] = 0.89; 95% confidence interval [CI] 0.79-1.02). The corresponding results were stable in the subgroup analyses. Specifically, smoking was not associated with an increased risk of postoperative atrial fibrillation regardless of the type of cardiac surgery: coronary artery bypass grafting (OR = 0.91; 95% CI 0.77-1.07), valve surgery (OR = 0.15; 95% CI 0.01-1.56), and coronary artery bypass grafting+valve surgery (OR = 0.91; 95% CI 0.70-1.18). CONCLUSIONS Based on currently published studies, smoking was not associated with an increased risk of postoperative atrial fibrillation in patients undergoing cardiac surgery.
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Affiliation(s)
- Qin Wan
- Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang of Jiangxi
| | - Siyuan Li
- Grade 2017, The Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Jian Hu
- Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang of Jiangxi
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Abstract
While intraoperative mortality has diminished greatly over the last several decades, the risk of death within 30 days of surgery remains stubbornly high and is ultimately related to perioperative organ failure. Perioperative strokes, while rare (<2% in noncardiac surgery), are associated with a more than 10-fold increase in mortality. Rapid identification and treatment are key to maximizing long-term outcomes. Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are separate but related perioperative neurological disorders, both of which are associated with poor long-term outcomes. To date, there are few known interventions that can ameliorate the risk of perioperative central nervous system dysfunction. Major adverse cardiac events (MACE) are a major contributor to adverse clinical outcomes following surgical procedures. Recently, advances in diagnostic strategies (eg, high-sensitivity cardiac troponin [hs-cTn] assays) have improved our understanding of MACE. Recently, the dabigatran in patients with myocardial injury after noncardiac surgery (MINS; Management of myocardial injury After NoncArdiac surGEry) trial demonstrated that a direct thrombin inhibitor could improve outcomes following MINS. While the risk of acute respiratory distress syndrome (ARDS) after surgery is approximately 0.2%, other less severe complications (eg, pneumonia, reintubation) are closer to 2%. While intensive care unit (ICU) concepts related to ARDS have migrated into the operating room, whether or not adverse pulmonary outcomes impact long-term outcomes in surgical patients remains a matter of debate. The standardization of acute kidney injury (AKI) definition has improved the ability of clinicians to measure and study the incidence of this important source of perioperative morbidity. AKI is associated with increased mortality as well as nonrenal morbidity (eg, myocardial infarction) after major surgery. Gastrointestinal complications after surgery range from ileus (common in abdominal procedures and associated with an increased length of stay) to less common complications such as mesenteric ischemia and gastrointestinal bleeding, both of which are associated with very high mortality. Outside of cardiothoracic surgery, the incidence of perioperative hepatic injury is not well described but, in this population, is associated with worsened long-term outcomes. Hyperglycemia is a common perioperative complication and occurs in patients undergoing both cardiac and noncardiac surgery. Both hyper- and hypoglycemia are associated with worsened long-term outcomes in cardiac and noncardiac surgery. Better diagnosis and increased understanding of perioperative organ injury has led to an increased appreciation for the specific role that particular organ systems play in poor long-term outcomes and has set the stage for targeted therapeutic interventions.
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45
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Goulden CJ, Hagana A, Ulucay E, Zaman S, Ahmed A, Harky A. Optimising risk factors for atrial fibrillation post-cardiac surgery. Perfusion 2021; 37:675-683. [PMID: 34034586 DOI: 10.1177/02676591211019319] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Postoperative atrial fibrillation (POAF) is an ongoing complication following cardiac surgery, with an incidence of 15%-60%. It is associated with substantial mortality and morbidity, as well increased hospital stays and healthcare costs. The pathogenesis is not fully understood, but the literature suggests that POAF occurs when transient, postoperative triggers act on vulnerable atrial tissue produced by preoperative, procedure-induced and postoperative processes such as inflammation, oxidative stress, autonomic dysfunction and electrophysiological remodelling of the atrial tissues. This sets the stage for arrhythmogenic mechanisms, such as ectopic firing secondary to triggered activity and re-entry mechanisms generating POAF. Preoperative factors include advanced age, sex, ethnicity, cardiovascular risk factors, preoperative drugs, electrocardiogram and echocardiogram abnormalities. Procedural factors include: the use of cardiopulmonary bypass and aortic cross clamp, type of cardiac surgery, use of hypothermia, left ventricular venting, bicaval cannulation and exclusion of the left atrial appendage. Postoperative factors include postoperative drugs, electrolyte and fluid balance and infection. This review explores the pathogenesis of POAF and the contribution of these perioperative factors in the development of POAF. Patients can be risk stratified for targeted treatment and prophylaxis, and how these factors can be attenuated to improve POAF outcomes following cardiac surgery.
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Affiliation(s)
- Christopher J Goulden
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Arwa Hagana
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Edagul Ulucay
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Sadia Zaman
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Amna Ahmed
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK
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46
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Nelson JA, Gue YX, Christensen JM, Lip GYH, Ramakrishna H. Analysis of the ESC/EACTS 2020 Atrial Fibrillation Guidelines With Perioperative Implications. J Cardiothorac Vasc Anesth 2021; 36:2177-2195. [PMID: 34130901 DOI: 10.1053/j.jvca.2021.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 11/11/2022]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide, with an individual lifetime risk of approximately 37% in the United States. Broadly defined as a supraventricular tachyarrhythmia with disorganized atrial activation, AF results in an increased risk of stroke, heart failure, valvular heart disease, and impaired quality of life, and confers a significant burden on the health of individuals and society. AF in the perioperative setting is common and a significant source of perioperative morbidity and mortality worldwide. The latest iteration of the European Society of Cardiology AF guidelines published in 2020 provide the clinician a valuable road map for the management of this arrythmia. This expert review will comprehensively analyze the 2020 European Society of Cardiology guidelines and provide perioperative management tools for the clinician.
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Affiliation(s)
- James A Nelson
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Ying X Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Jon M Christensen
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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47
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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48
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Incidence, Risk Factors, and Outcomes of Perioperative Atrial Fibrillation following Noncardiothoracic Surgery: A Systematic Review and Meta-Regression Analysis of Observational Studies. Anesthesiol Res Pract 2021; 2021:5527199. [PMID: 34007270 PMCID: PMC8099514 DOI: 10.1155/2021/5527199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/08/2021] [Accepted: 04/19/2021] [Indexed: 11/18/2022] Open
Abstract
Background Atrial fibrillation (AF) occurs in 16-30% of patients after cardiac and thoracic surgery and can lead to serious complications like hypoperfusion of vital organs, pulmonary edema, and myocardial infarction. The evidence on risk factors and complications associated with perioperative AF after noncardiothoracic surgery is limited. Methods The primary objective was to determine demographic and clinical risk factors for new-onset atrial fibrillation associated with noncardiothoracic surgery. A secondary aim was to identify the incidence and odds of perioperative complications associated with the new-onset atrial fibrillation. A systematic search within multiple databases was conducted for studies that explicitly reported on new-onset atrial fibrillation after noncardiothoracic surgery. We reported data on demographics, comorbidities, and perioperative complications as mean difference (MD) or odds ratios (OR) and corresponding 95% confidence interval (CI) using random effects models. A two-sided P value of less than 0.05 was considered significant. We performed meta-regression and sensitivity analysis of various subgroups to confirm the inference of our findings. Results Eleven studies reporting on 121,517 patients were included, of whom 2,944 developed perioperative AF (incidence rate: 3.7%; 95% CI: 2.3%--6.2%). Advanced age (AF group versus control group: 69.36 ± 10.5 versus 64.37 ± 9.53 years; MD: 4.06; 95% CI: 1.67--6.44; P=0.0009), male gender (52.85% versus 43.59%; OR: 1.08; 95% CI: 0.54 to 1.62; I 2: 84%; P < 0.0001), preoperative hypertension (60.42% versus 56.51%; OR: 1.15; 95% CI: 1.08 to 1.23; I 2: 0%; P < 0.00001), diabetes mellitus (22.6% versus 23.04%; OR: 0.97; 95% CI: 0.89 to 1.05; I 2: 0; P < 0.00001), and cardiac disease (30.64% versus 8.49%; OR: 2.3; 95% CI: 0.28 to 4.31; I 2: 93%; P=0.03) were found to be significant predictors for perioperative AF. The AF group was at increased odds of developing postoperative cardiac complications (34.1% versus 5%; OR: 5.44; 95% CI: 0.49 to 10.39; I 2: 82%; P=0.03), postoperative stroke (0.5% versus 0.1%; OR: 3; 95% CI: 0.65 to 5.35; I 2: 0%; P=0.01), and mortality (7.40% versus 1.92%; OR: 3.58; 95% CI: 0.14 to 7.02; I 2: 0%; P=0.04). Study quality assessment by meta-regression and sensitivity analysis of the various subgroups did not affect the final inference of the results. Conclusion We identified advanced age, male gender, preoperative hypertension, diabetes mellitus, and cardiac disease as important risk factors for perioperative atrial fibrillation. The atrial fibrillation group was at increased odds for postoperative cardiac complications, stroke, and higher mortality, emphasizing the need for risk stratification and close monitoring.
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49
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Hsu JC, Huang CY, Chuang SL, Yu HY, Chen YS, Wang CH, Lin LY. Long Term Outcome of Postoperative Atrial Fibrillation After Cardiac Surgery-A Propensity Score-Matched Cohort Analysis. Front Cardiovasc Med 2021; 8:650147. [PMID: 33987211 PMCID: PMC8112811 DOI: 10.3389/fcvm.2021.650147] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/01/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Postoperative atrial fibrillation (POAF) results in a longer hospital stay and excess mortality. However, whether POAF would increase stroke rate has been debated for years. When and how long should anticoagulation be used to prevent stroke are unknown. In the study, we planned to investigate the clinical demographics and long-term outcomes of POAF after cardiac surgery in a single-center cohort. Methods: The cohort study used a database from National Taiwan University Hospital, a single tertiary medical center in Taiwan, between 2007 and 2017, to identify patients with prior normal sinus rhythm developing POAF after cardiac surgery. Patients without POAF after cardiac surgery were used as controls. Propensity score matching with 1:1 ratio and Cox regression models were employed to estimate the risk of transient ischemic accident (TIA) or ischemic stroke. Results: From 2007 to 2017, a total of 8,374 patients received open-heart surgery, in which 1,585 patients with a history of AF were excluded. The overall incidence of TIA/ischemic stroke was 3.9% in a median 9.2-years of follow-up. After propensity matching, 1,965 matched paired subjects were included for analysis. Postoperative atrial fibrillation was associated with an increased risk of future AF [Hazard ratio (HR) 1.40, 95% confidence interval (95%CI) = 1.09–1.79, p = 0.008] and heart failure (HF) hospitalization (HR 1.58, 95%CI 1.23–2.04, p < 0.001); however, POAF did not significantly correlate with the risk of TIA/ischemic stroke (HR 1.17, 95%CI 0.85–1.60, p = 0.043). Kaplan-Meier analysis showed that POAF was a significant predictor for future AF, HF hospitalization, and overall mortality, but not for TIA/ischemic stroke. Conclusion: In the Asian population, POAF after cardiac surgery increased the risk of future AF, HF, and overall mortality, but was not associated with future TIA/ischemic stroke.
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Affiliation(s)
- Jung-Chi Hsu
- Division of Cardiology, Department of Internal Medicine, Camillian Saint Mary's Hospital Luodong, Yilan, Taiwan.,Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chen-Yu Huang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Division of Cardiology, Department of Internal Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - Shu-Lin Chuang
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Hsu-Yu Yu
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yih-Sharng Chen
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Hsien Wang
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Lian-Yu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Division of Electrophysiology, Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
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50
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Hung LT, Alshareef A, Al-Ahdal TMA, Anh PTT, Huan DQ, Do Van Trang, Zia S, Van Sy H, Huy NT. Predicting atrial fibrillation after cardiac surgery using a simplified risk index. J Electrocardiol 2021; 67:45-49. [PMID: 34023539 DOI: 10.1016/j.jelectrocard.2021.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/11/2021] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery and can lead to increased risk of postoperative adverse events. However, atrial fibrillation and postoperative adverse events are preventable. In this study, a risk index was developed to predict atrial fibrillation after cardiac surgery. METHODS A prospective cohort study of 405 patients who had undergone adult cardiac surgery from 2015 September to 2016 August at Heart Institute of HCMC and Cho Ray Hospital were obtained. In order to predict POAF, a logistic regression model was developed, and a risk score was derived and validated by bootstrap. RESULTS In our study, 98 patients developed POAF (24.2%). The risk score included three significant risk factors (age ≥ 60, left atrial diameter > 41 mm, Coronary Artery Bypass Graft with concomitant mitral valve replacement or repair) that were consistent with other reports. Each of these risk factors was assigned one point. The total risk score ranges from 0 to 3 (AUC = 0.69, 95% CI: 0.63-0.75) with the best cutoff point at 1. According to this scoring system, the incidences of POAF in patients associated with each score of 0, 1, 2, and 3 were 8.6%, 30.1%, 40.8%, and 58.3% respectively. Bootstrapping with 5000 samples confirmed the final model provided was consistent with predictions. CONCLUSIONS We developed and validated a simple risk score based on clinical variables that can be obtained before surgery in order to accurately predict the risk of POAF in patients undergoing cardiac surgery.
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Affiliation(s)
- Le Thanh Hung
- Heart Institute, Ho Chi Minh City, Viet Nam; Online Research Club (http://www.onlineresearchclub.org), Nagasaki, Japan.
| | - Abdulmueti Alshareef
- Online Research Club (http://www.onlineresearchclub.org), Nagasaki, Japan; Faculty of Medicine, University of Zawia, AZ zawiyah, Libya.
| | - Tareq Mohammed Ali Al-Ahdal
- Online Research Club (http://www.onlineresearchclub.org), Nagasaki, Japan; Department of Public Health, Faculty of Medicine, Jordan University of Science and Technology, Jordan.
| | | | | | | | - Sairah Zia
- Online Research Club (http://www.onlineresearchclub.org), Nagasaki, Japan; American University of the Caribbean Medical School, Cupe Coy, Sint Maarten
| | - Hoang Van Sy
- Department of Internal Medicine, Faculty of Medicine, University of Medicine and Pharmacy, Ho Chi Minh City, Viet Nam; Internal Cardiology Department of Cho Ray Hospital, Viet Nam.
| | - Nguyen Tien Huy
- Online Research Club (http://www.onlineresearchclub.org), Nagasaki, Japan; School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki 852-8523, Japan.
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