Early Transthoracic Echocardiography after Cardiac Surgery Predicts Postoperative Atrial Fibrillation

Clinical practices for defining, detecting, and diagnosing postoperative atrial fibrillation after coronary revascularization surgery - A scoping review

OBJECTIVES

This scoping review was undertaken to understand the degree of variation in clinical practices associated with postoperative atrial fibrillation (POAF), following coronary revascularization surgery by collating and synthesising key concepts from current published literature.

REVIEW METHODS AND DATA SOURCES

This scoping review was conducted following the framework outlined by Askey and O'Malley. Reporting of this scoping review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Initial searches were completed in September 2020 and updated in January 2023. Comprehensive searches to identify relevant published literature were carried out within CINAHL, MEDLINE, and ProQuest databases. All searches were limited to full-text papers published in English with human adult participants. Deductive content analysis using NVivo software was performed to synthesise the data.

RESULTS

A total of 692 studies were identified during the database searches. After the deletion of duplicates and the application of the inclusion and exclusion criteria, 73 studies were included in the scoping review. The included studies were published between 2001 and 2022 and included a total of 24,833 participants. Forty-six studies included a definition of POAF, with four of these citing a peak-body definition. A total of 24 included studies reported on electrocardiogram diagnostic criteria for POAF, with 13/24 [54%] describing these characteristics within their definition. The time-based diagnostic criteria ranged from a minimum duration of greater than 30 seconds to greater than 1 hour. The most frequently reported minimum-time thresholds were ≥30 seconds, reported in 12 of 51 (24%) studies and ≥5 min, reported in 13 of 51 (25%) studies.

CONCLUSIONS

There is a lack of consistency in clinical practice for defining, detecting, and diagnosing POAF, following coronary revascularization surgery. Consensus and standardisation of clinical practices are urgently needed.

Predicting atrial fibrillation after cardiac surgery: a scoping review of associated factors and systematic review of existing prediction models

INTRODUCTION

Postoperative atrial fibrillation (POAF) is common after cardiac surgery and associated with increased hospital length of stay, patient morbidity and mortality. We aimed to identify factors associated with POAF and evaluate the accuracy of available POAF prediction models.

METHODS

We screened articles from Ovid MEDLINE® and PubMed Central® (PMC) and included studies that evaluated risk factors associated with POAF or studies that designed or validated POAF prediction models. We only included studies in cardiac surgical patients with sample size n ⩾ 50 and a POAF outcome group ⩾20. We summarised factors that were associated with POAF and assessed prediction model performance by reviewing reported calibration and discriminative ability.

RESULTS

We reviewed 232 studies. Of these, 142 fulfilled the inclusion criteria. Age was frequently found to be associated with POAF, while most other variables showed contradictory findings, or were assessed in few studies. Overall, 15 studies specifically developed and/or validated 12 prediction models. Of these, all showed poor discrimination or absent calibration in predicting POAF in externally validated cohorts.

CONCLUSIONS

Except for age, reporting of factors associated with POAF is inconsistent and often contradictory. Prediction models have low discrimination, missing calibration statistics, are at risk of bias and show limited clinical applicability. This suggests the need for studies that prospectively collect AF relevant data in large cohorts and then proceed to validate findings in external data sets.

Early Left Ventricular Global Longitudinal Strain Deterioration After Aortic Aneurysm Repair: Impact of Aortic Stiffness

PURPOSE

To associate the impact of aortic reconstruction using currently available grafts and endografts on pulse wave velocity in patients with abdominal aortic aneurysm (AAA) and to evaluate its effect on early cardiac systolic function indices.

MATERIALS AND METHODS

Seventy-three consecutive patients with AAA (mean age 70±8 years; all men) who underwent open (n=12) or endovascular repair (EVAR; n=61) were prospectively enrolled in an observational cohort study. Left ventricular global longitudinal strain (GLS; an important diagnostic and prognostic index of early systolic dysfunction) and carotid-femoral pulse wave velocity (cf-PWV) were estimated 1 week preoperatively, as well as at 1 and 6 months postoperatively.

RESULTS

A significant time effect was found for cf-PWV, which showed an increase at 1 month that remained through 6 months (p=0.007). Additionally, a deterioration in GLS values was revealed, with a significant change at 1 month that persisted 6 months later (p<0.001). No significant group effect was observed between EVAR and open repair (p=0.98), and there was no significant interaction (p=0.96). Notably, the difference in GLS between baseline and 6 months significantly correlated with the corresponding changes in cf-PWV (r=0.494, p<0.001).

CONCLUSION

AAA repair leads not only to an increase in aortic stiffness, as measured by the increase in pulse wave velocity, but also to reduced cardiac systolic function. Our findings highlight the need for a more intense cardiac surveillance program after aortic reconstruction. Further studies are needed to investigate how this may translate into long-term manifestations of cardiovascular complications and symptomatology.

Adverse remodeling in atrial fibrillation following isolated aortic valve replacement surgery

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia with adverse clinical outcomes. Aortic valve replacement (AVR) is one of the most frequently performed cardiac surgeries, although there is scarce evidence on arrhythmic outcomes. We aimed to evaluate AF during the first year post- isolated aortic valve replacement surgery and its clinical, analytical, and echocardiographic predictors.

METHODS

Severe aortic stenosis patients with no prior atrial fibrillation submitted to isolated aortic valve replacement surgery were included in our study, of which 316 remained in sinus rhythm and 24 developed AF. We performed logistic regression searching for AF predictors and a longitudinal comparison between pre and post-operative echocardiographic data.

RESULTS

Postoperative AF (POAF), diabetes, and follow-up indexed Left Atrium Diameter (iLAD) were significantly higher in the group of patients developing AF. POAF and iLAD were independent AF predictors at follow-up. No differences between groups were found regarding baseline and follow-up echocardiographic data except for indexed Left Ventricle End-diastolic Diameter (LVED), which failed to decrease after surgery in the AF group.

CONCLUSIONS

POAF and iLAD independently predicted AF at 1 year following isolated AVR surgery in aortic stenosis patients with no AF history. iLVED did not decrease significantly at follow-up in AF patients, possibly reflecting adverse ventricular remodeling.

The role of the right atrium in development of postoperative atrial fibrillation: A speckle tracking echocardiography study

PURPOSE

Atrial fibrillation (AF) is relatively frequent in the postoperative period, and is associated with an increased frequency of adverse events. The role of right atrial (RA) volume and functions in the development of AF is unknown. In this study, we investigated the effect of RA echocardiographic indices on AF development in the postoperative period.

METHOD

We enrolled 142 consecutive patients who underwent coronary artery bypass surgery, and assigned them into two groups depending on the occurrence or not of AF development in the postoperative period.

RESULTS

A propensity score matching analysis was performed to balance the groups, and 37 pairs were eventually included in the analysis. The median age was 67.5 (63-75) years and 73.3% of them were males. In the univariate analysis, right atrial volume index (RAVi), right atrial strain during reservoir phase (RASr), left ventricular global longitudinal strain, right ventricular strain, left atrial volume index, left atrial strain during reservoir phase, and systolic pulmonary artery pressure were associated with AF development. In the regression analysis, we found that RAVi (OR: 3.1, 95% CI: 2.2-6.3, P: .033) and RASr (OR: 0.82, 95% CI: 0.67-0.93, P: .048) were independent predictors of AF development.

CONCLUSIONS

RA structure and functions are closely associated with AF development in the postoperative period, and screening of RA functions prior to surgery may be useful for preventing AF development.

Practical approach to diastolic dysfunction in light of the new guidelines and clinical applications in the operating room and in the intensive care

There is growing evidence both in the perioperative period and in the field of intensive care (ICU) on the association between left ventricular diastolic dysfunction (LVDD) and worse outcomes in patients. The recent American Society of Echocardiography and European Association of Cardiovascular Imaging joint recommendations have tried to simplify the diagnosis and the grading of LVDD. However, both an often unknown pre-morbid LV diastolic function and the presence of several confounders-i.e., use of vasopressors, positive pressure ventilation, volume loading-make the proposed parameters difficult to interpret, especially in the ICU. Among the proposed parameters for diagnosis and grading of LVDD, the two tissue Doppler imaging-derived variables e' and E/e' seem most reliable. However, these are not devoid of limitations. In the present review, we aim at rationalizing the applicability of the recent recommendations to the perioperative and ICU areas, discussing the clinical meaning and echocardiographic findings of different grades of LVDD, describing the impact of LVDD on patients' outcomes and providing some hints on the management of patients with LVDD.

Hemodynamic parameters predict the risk of atrial fibrillation after cardiac surgery in adults

BACKGROUND

Postoperative atrial fibrillation (POAF) is a common complication following cardiac surgery and is associated with poorer prognosis. This study attempted to evaluate whether hemodynamic parameters determined by a right heart catheter predict the occurrence of POAF.

HYPOTHESIS

We hypothesized that atrial fibrillation after cardiac surgery can be predicted by hemodynamic parameters determined by a right heart catheter.

METHODS

Between October 2015 and January 2017, 126 patients with preoperative sinus rhythm undergoing coronary artery bypass grafting and/or aortic valve replacement were enrolled in this study. Complete echocardiographic examination was performed preoperatively, and hemodynamic parameters were recorded via a right heart catheter before anesthesia induction. Postoperative telemetry strips and electrocardiogram were used to detect atrial fibrillation until discharge. Multivariate logistic regression was used to identify risk factors of POAF.

RESULTS

The overall incidence of POAF was 40/126 (31.7%). Multivariate logistic regression analysis determined that left atrial dimension (LAD) (adjusted odds ratio [OR]: 1.118, 95% confidence interval [CI]: 1.020-1.227, P = 0.018), pulmonary capillary wedge pressure (PCWP) (adjusted OR: 1.225, 95% CI: 1.082-1.387, P = 0.001), and pulmonary artery systolic pressure (PASP) (adjusted OR: 1.076, 95% CI: 1.019-1.137, P = 0.008) were significant predictors of POAF.

CONCLUSIONS

The present study suggested that LAD, PCWP, and PASP were robust predictors of POAF. These parameters may indicate a patient's susceptibility toward developing POAF and help to identify patients who need preventive treatment.